Sunrise request of the Arizona Midwifery Institute

Arizona House of Representatives
House Majority Research
MEMORANDUM
Kristine Stoddar~
Assistant Legislative Research Analyst
(602) 926-5299
To: JOINT LEGISLATIVE AUDIT COMMITTEE
1700 W. Washington
Phoenix, AZ 85007-2848
FAX (602) 417-3140
cc: Representative Rick Murphy, Chair
Senator Jim Waring, Vice-Chair
Re: Sunrise application of the Arizona Midwifery Institute
Date: December 2, 2005
Attached is the final report ofthe sunrise request submitted by the Arizona Midwifery Institute,
which was conducted by the Senate Health and House of Representatives Health Committee of
Reference.
This report has been distributed to the following individuals and agencies:
Governor ofthe State ofArizona
The Honorable Janet Napolitano
President ofthe Senate
Senator Ken Bennett
Senate Members
Senator Jim Waring, Vice-Chair
Senator Carolyn Allen
Senator Marsha Arzberger
Senator Robert Cannell
Senator Barbara Leff
Arizona Midwifery Institute
Department of Library, Archives & Public Records
Auditor General
Senate Republican Staff
Senate Research Staff
Senate Democratic Staff
Speaker ofthe House of Representatives
Representative Jim Weiers
House Members
Representative Rick Murphy, Chair
Representative David Bradley
Representative Laura Knaperek
Representative Linda Lopez
Representative Doug Quelland
House Majority Staff
House Research Staff
House Democratic Staff
Senate Health and House ofRepresentatives Health
Committee ofReference Report
Sunrise Request ofArizona Midwifery Institute
Date: December 2, 2005
To: Joint Legislative Audit Committee
Representative Rick Murphy, Chair
Senator Jim Waring, Vice-Chair
Background
Pursuant to Arizona Revised Statutes (ARS) §32-3104, the Joint Legislative Audit
Committee assigned a sunrise review for licensed midwives to the Senate Health and
House of Representatives Health Committee of Reference. Attached is a copy of the
application submitted by the Arizona Midwifery Institute (Institute).
Authorized by Laws 1957, Chapter 45, §1 the Midwife Licensing Program licenses and
regulates midwife services in Arizona. The Midwife Licensing Program is administered
by the Office of Special Licensure within the Arizona Department of Health Services
(DHS). Current state law and DHS rule prohibits licensed midwives from providing care
to any woman who has a history of or develops serious conditions including a previous
Cesarean section, a history of severe postpartun bleeding, sexually transmitted diseases,
unhealthy blood pressure levels, premature labor, abnormal fetal heart rate, postpartum
hemorrhage, etc. Furthermore, licensed midwives must obtain medical consultation to
obtain a recommendation for treatment, referral or transfer of care at any time that their
client is determined to have serious medical problems during their pregnancy.
DHS rule further stipulates that, in emergency situations, licensed midwives may only
perform the following procedures:
1. Cardiopulmonary resuscitation of the mother or newborn;
2. Administration of oxygen at no more than 8 liters per minute via mask for the
mother and 5 liters per minute for the newborn via neonatal mask;
3. Midline episiotomy to expedite the delivery during fetal distress;
4. Suturing of episiotomy or tearing of the perineum, to stop active bleeding,
following administration of local anesthetic, contingent upon physician
consultation or standing orders of physician;
5. Release of shoulder dystocia by rotating the shoulders into one of the oblique
diameters of the pelvis; and
6. Manual exploration of the uterus for control of severe bleeding.
The Arizona Midwifery Institute is requesting that the Legislature grant licensed
midwives a scope of practice increase by amending the licensed midwives statute to
permit Arizona licensed midwives to obtain, possess and administer, without the orders
ofa physician, the following:
• Oxytocins
RH immunoglobin
• IV fluid replacement
• Local anesthetics
• Vitamin K
• Eve prophylaxis
Oxygen
• Devices for rupturing the amniotic sac
• Devices for repairing birth reiated lacerations
• Specified devices for resuscitation
• Devices for the administration of intravenous fluids
• Needles and syringes
Committee ofReference Sunrise Review Procedures
The Committee of Reference held one public meeting on November 8, 2005 to review the
Institute's sunrise application as required by ARS §32-3104 and to hear public testimony
on the proposed changes.
Committee ofReference Recommendations
The Committee of Reference recommends that the Legislature expand the scope of
practice for Arizona's licensed midwives by allowing procurement, possession, and
administration of various medical devices and medications, which will be specified in
legislation.
Attachments:
1. Sunrise application submitted by the Arizona Midwifery Institute.
2. Meeting notice.
3. Minutes of the Committee of Reference meeting.
Elizabeth Basl~ett
Health Comnrittee Analyst
(602) 926-3072
Arizona House of Representatives
House Majority Research
MEMORANDUM
1700 W. Washington
Phoenix,AZ 85007-2848
FAX (602) 417-3095
To: Members ofthe House Health and Senate Health Committees ofReference
Re: Sunrise Request of the Arizona Midwifery Institute
Date: October 26, 2005
The following is some background information regarding the request for an increase in the scope
ofpractice for licensed midwives. Also attached is a copy of the sunrise application submitted by
the Arizona Midwifery Institute (AMI). A public meeting is scheduled for November 8th to allow
you to ask questions, take public testimony and make a final recommendation on the sunrise
application. If you have questions or need additional information, please feel free to contact me.
BACKGROUND
According to statute, a midwife is a person who delivers a baby or provides health care related to
pregnancy, labor, delivery and postpartum care of the mother and her baby. A midwife is not a
physician. A midwife practices the independent management of care for healthy, low· risk
women, and their infants during pregnancy, labor and birth, and in the first few weeks after birth.
In this state, midwives are authorized to deliver babies in the home. In Arizona, there are two
types of midwives who may legally assist a woman with childbirth: a certified nurse midwife
and a licensed midwife. The Sunrise application only applies to licensed midwives because
certified nurse midwives already have prescription privileges.
Authorized by Laws 1957, Chapter 45, §1 the Midwife Licensing Program licenses and regulates
midwife services in Arizona. The Midwife Licensing Program is administered by the Office of
Special Licensure within the Arizona Department ofRealth Services (DRS).
October 26, 2005
According to A.R.S. § 36-755(B) 4 and Arizona Administrative Code Title 9, Chapter 16, to
qualify for a midwife license, an applicant must be at least 18 years old; have a high school
diploma or its equivalent; be of good moral character; be currently certified by the American
Heart Association in adult basic cardiopulmonary resuscitation and be currently certified by the
American Academy of Pediatrics in neonatal cardiopulmonary resuscitation. Additionally,
applicants must submit a letter of recommendation from a certified nurse-midwife, a licensed
midwife, or a physician and a letter of recommendation from a mother for whom the applicant
has provided midwifery services. A license must be renewed biennially. Furthermore, DHS rule
requires an applicant for midwifery take a three part examination consisting of a written section,
oral section and a practical section. Applicants must receive a grade of 80% or higher to be
licensed.
Licensed midwives are also required to obtain 10 continuing education units which are related to
maintaining the skills and judgment necessary to:
1. Assess a client for acceptance and monitor the client's ongoing condition;
2. Plan and manage care during the normal prenatal, intra partum, and postpartum
periods;
3. Intervene when the client's condition deviates from normal.
4. Provide emergency assistance, as permitted, until medical care can be obtained;
5. Offer anticipatory guidance and support on an ongoing basis for the client and family
including nutritional counseling, substance abuse cessation, encouragement for early
and continuous care for mother and infant, and motivate the client to establish a
relationship with a primary care provider; and
6. Provide referral services to medical and community services as appropriate for the
client's needs.
There are approximately 54 Arizona licensed midwives. Midwives currently practice in 7
counties in Arizona. There is not a state approved program of midwifery training in Arizona at
this time.
SCOPE OFPRACTICE INCREASE
Current state law and DRS rule prohibits licensed midwives from providing care to any woman
who has a history of or develops serious conditions including a previous Cesarean section, a
history of severe postpartun bleeding, sexually transmitted diseases, unhealthy blood pressure
levels, premature labor, abnormal fetal heart rate, postpartum hemorrhage, etc. Furthermore,
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October 26, 2005
licensed midwives must obtain medical consultation to obtain a recommendation for treatment,
referral or transfer of care at any time that their client is determined to have serious medical
problems during their pregnancy.
DHS rule further stipulates that, in emergency situations, licensed midwives may only perform
the following procedures:
1. Cardiopulmonary resuscitation ofthe mother or newborn;
2. Administration of oxygen at no more than 8 liters per minute via mask for the mother
and 5 liters per minute for the newborn via neonatal mask;
3. Midline episiotomy to expedite the delivery during fetal distress;
4. Suturing of episiotomy or tearing of the perineum, to stop active bleeding, following
administration of local anesthetic, contingent upon physician consultation or standing
orders ofphysician;
5. Release of shoulder dystocia by rotating the shoulders into one of the oblique
diameters of the pelvis; and
6. Manual exploration ofthe uterus for control of severe bleeding.
Additionally, current law limits a licensed midwife to administering a maximum does of 20 units
ofpitocin intramuscularly, in lO-unit dosages each, 30 minutes apart, to a client for the control of
postpartum hemorrhage, contingent upon physician consultation or standing orders by a
physician, and arrangements for immediate transport of the client to a hospital.
The Arizona Midwifery Institute is requesting that the Legislature grant licensed midwives a
scope of practice increase by amending the licensed midwives statute to permit Arizona
licensed midwives to obtain, possess and administer, without the orders of a physician, the
following:
•
��
•
•
•
•
•
•
•
•
•
Oxytocins
RH immunoglobin
IV fluid replacement
Local anesthetics
VitaminK
Eve prophylaxis
Oxygen
Devices for rupturing the amniotic sac
Devices for repairing birth related lacerations
Specified devices for resuscitation
Devices for the administration ofintravenous fluids
Needles and syringes
3
October 26, 2005
According to the AMI, the scope of practice increase has only recently become necessary
because of current malpractice issues in Arizona. Specifically, the AMI alleges that malpractice
insurance companies are restricting physicians from prescribing the abovementioned medications
and devices for use by midwives. Additionally, the AMI states that the current Arizona law
presents obstacles to safe homebirth deliveries by "limiting skilled professional midwives access
to necessary drugs and devices." The AMI also states that allowing midwives access to
emergency and non-emergency medications and devices would enable midwives to practice
within their skills and educational level.
According to the AMI "the benefit to the consumer, who for personal or economical reasons
prefer homebirths, is that midwives will be able to provide safer outcomes for mother and their
families."
OTHER STATES
About 27 states authorize the administration of specified medications/drugs and devices.
Although some states allow certified nurse-midwives prescriptive authority, staff was only able
to identify five states that authorize licensed midwives to prescribe medications/drugs and
devices, these state laws are detailed below. It important to note that several state laws are silent
on the issue and several states authorize the health department or health profession board to
prescribe rules regarding medications and devices.
Oregon - Oregon state law allows a licensed midwife to purchase and administer authorized
scheduled legend drugs and devices that are used in pregnancy, birth, postpartum care, newborn
care or resuscitation and that are deemed integral to providing safe care to the public by the State
Board of Direct Entry Midwifery by rule. Legend drugs authorized are limited to prophylactic
ophthalmic medications, vitamin K and oxygen; and Rho (D) immune globulin, epinephrine,
intravenous fluids, local anesthetic and legend devices for injection of medications, for the
administration of intravenous fluids, for adult and infant resuscitation and for rupturing the
amniotic membranes. Pharmacists who dispense drugs and devices to a licensed midwife are not
liable for any adverse reactions caused by administration of the legend drugs and devices by the
midwife.
Washington - Washington administrative rule allows a licensed midwife to obtain and
administer prophylactic ophthalmic medication, postpartum oxytocic, vitamin K, Rho immune
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October 26, 2005
globulin and local anesthetic. A pharmacist who dispenses such drugs to a licensed midwife is
not liable for any adverse reactions caused by any method of use by the midwife.
New Hampshire - New Hampshire state law allows a licensed midwife to obtain, without
prescription, the following medications: Rh immune globin (Rhogam), Eye prophylaxis.
Oxygen, Lidocaine Hydrochloride by infiltration and suture material,Vitamin K by injection or
oral vitamin, Oxytocins such as pitocin, ergotrate, and methergine, by injection or orally and
Intravenous fluids. A pharmacist who dispenses such medications to a certified midwife is not
liable for any adverse reactions caused by any method of use by the midwife.
New York - New York law grants a licensed midwife the authority, as necessary, limited to the
practice of midwifery and subject to limitations in the written agreement, to prescribe and
administer drugs, immunizing agents, diagnostic tests and devices, as established by the health
board in accordance with the health commissioner's regulations. A midwife must obtain a
certificate upon successfully completing a program including a pharmacology component, or its
equivalent, as established by the commissioner's regulations prior to prescribing medications or
devices.
Utah - Utah State created a Licensed Direct-entry Midwife Formulary Committee charged with
the adoption of a licensed direct-entry midwife formulary. A rule was then adopted to include
prescription drugs which may be obtained by a licensed midwife and the standards, conditions
and guidelines for the use ofprescription drugs included in the formulary.
5
1. A definition of the problem and why a change in the scope of practice is necessary,
including the extent to which consumers need and will benefit from licensed midwives with
this scope of practice.
This sunrise application seeks permission and direction, pursuant to A.RS.§ 32-3106, to
amend the licensed midwife statute topermit Arizona licensed midwives to obtain, possess and
administer the following:
• Oxytocins
• RH immunoglobin
• N fluid replacement
• Local anesthetics
• VitaminK
• Eye prophylaxis
• Oxygen
• Devices for rupturing the amniotic sac
• Devices for repairing birth relatedlacerations
• Specified devices for resuscitation
• Devices for the administration ofintravenous fluids
• Needles and syringes
The reason this has not been a problem until now is because ofcurrent malpractice insurance
issues in Arizona. Previously, malpractice insurance companies did not restrict physicians to
work with midwives by prescribing the abovementioned medications and devices.
This increased scope of practice would permit licensed midwives to practice within the
framework ofthe International Definition ofMidwifery:
"Amidwife is a person who, having been regularly admitted to a midwifery educational
program, duly recognized in the country in which it is located, has successfully
completed the prescribed course ofstudies in midwifery and has acquired the requisite
qualifications to be registered and/orlegally licensed to practice midwifery.
She must be able to give the necessary supervision, care and advice to women during
pregnancy, labor and the postpartum period, to conduct deliveries on her own
responsibility andto.care for the newborn and the infant This care includes preventative
measures, the detection ofabnormal conditions in mother and child, the procurement of
medical assistance and the execution ofemergency measures in the absence ofmedical
help. She has an important task in health counseling and education, not only for the
women, but also within the family and the community. The work should involve
antenatal education and preparation for parenthood and extends to certain areas of
gynecology, family planning and child care. She may practice in hospitals, clinics,
health units, domiciliary conditions or in any other service."
This definition is accepted by the WorId Health Organization and the International
Confederation ofMidwives. Currently, in the United States, there are about 27 states that allow
the administration ofthe abovementioned medications/drugs and devices bymidwives who are
either licensed or certified.
I
The benefit to the consumer, who for personal or economic reasons prefers homebirths, is
that midwives will be able to provide safer outcomes for mothers and their families.
According to the British Medical Journal in late June 2005:
"Researchers looked at more than 5,000 planned home births with professional
midwives in the U.S. and Canada. They found 87 percent ofmothers and babies did not
need to be transferred to a hospital."
Further, the average homebirth costs about 60 percent less than a hospital birth. Additionally:
"The study also found the use ofmedical interventions, such as forceps, epidurals, and
Caesarian Sections to be less than half ofthose in low-risk hospital births." ,
The current Arizona law presents obstacles to safe homebirth deliveries by limiting skilled
professional midwives access to necessary drugs and devices. Further, allowingmidwives access
to certain emergency and nonemergency medications and devices would enable midwives to
practice within their skills and education level.
2. The extent to which the public can be confident that qualified practitioners are competent.
Arizona Administrative Code Title 9, Chapter 16 describes current education requirements
for all midwives licensed by the Arizona Department ofHealth Services.
Additionally, skilled professional midwives licensed to practice midwifery in Arizona are
required to continue their education with current Continuing Education Units per Arizona
legislation. Lastly, the role ofthe Arizona Midwifery Institute (AMI), Code ofEthics, midwifery
model ofcare and supporting the role ofmidwives will aid midwives in maintaining skills and
working to improve midwifery services. The AMI mission statement follows:
"The Arizona Midwifery Institute is a professional organization dedicated to
strengthening relationships among health care professionals, legislators, and the
community to promote and implement the Midwives Model of Care."
3. The extent to which an increased scope of practice may harm the public.
The applicants anticipate that significant client and health benefits will follow from the
enactment of the proposed practice expansion and anticipate no harm to the public from the
appropriate acquisition and administration ofthe aforementioned drugs and devices.
This enactment will ensure that mothers and their families receive the highest quality ofcare
midwives can provide.
4. The estimated cost to the state and the general public of implementing the proposed
increase in scope of practice.
There is no financial impact to the state or the public for midwives to obtain, possess and
administer the aforementioned drugs and devices.
Interim agendas can be obtained via the Internet at http://www.azleg.state.az.us/lnterimCommittees.asp
ARIZONA STATE LEGISLATURE
INTERIM MEETING NOTICE
OPEN TO THE PUBLIC
SENATE HEALTH AND HOUSE OF REPRESENTATIVES HEALTH
COMMITTEE OF REFERENCE FOR THE:
SUNSET OF THE HEALTH FACILITIES AUTHORITY
SUNSET OF THE MEDICAL RADIOLOGIC TECHNOLOGY BOARD OF EXAMINERS
SUNSET OF THE NURSING CARE INSTITUTION ADMINISTRATION AND ASSISTED LIVING
SUNSET OF THE BOARD OF HOMEOPATHIC MEDICAL EXAMINERS
SUNRISE REQUEST OF THE ARIZONA ASSOCIATION FOR HOME CARE
SUNRISE REQUEST OF THE ARIZONA MIDWIFERY INSTITUTE
SUNRISE REQUEST OF THE ARIZONA ALLIANCE OF SURGICAL SPECIALISTS
Date:
Time:
Place:
Tuesday, November 8,2005
9:00 a.m.
House Hearing Room 1
AGENDA
1. Call to Order - Opening Remarks
2. Health Facilities Authority
• Presentation by the Health Facilities Authority
• Public Testimony
• Discussion and Recommendations by Committee of Reference
3. Medical Radiologic Technology Board of Examiners
• Presentation by the Medical Radiologic Technology Board of Examiners
• Public Testimony
• Discussion and Recommendations by Committee of Reference
4. Nursing Care Institution Administration and Assisted Living Facility Managers Board
• Presentation by the Nursing Care Institution Administration and Assisted Living
Facility Managers Board
• Public Testimony
• Discussion and Recommendations by Committee of Reference
5. Board of Homeopathic Medical Examiners
• Presentation by the Board of Homeopathic Medical Examiners
• Public Testimony
• Discussion and Recommendations by Committee of Reference
6. Arizona Alliance of Surgical Specialists
• Presentation by the Arizona Alliance of Surgical Specialists
• Public Testimony
• Discussion and Recommendations by Committee of Reference
7. Arizona Association for Home Care
• Presentation by the Arizona Association for Home Care
• Public Testimony
• Discussion and Recommendations by Committee of Reference
8. Arizona Midwifery Institute
• Presentation by the Arizona Midwifery Institute
• Public Testimony
• Discussion and Recommendations by Committee of Reference
9. Adjourn
Members:
Senator Jim Waring, Co-Chair
Senator Carolyn Allen
Senator Marsha Arzberger
Senator Robert Cannell
Senator Barbara Leff
10/31/05
jmb
Representative Rick Murphy, Co-Chair
Representative David Bradley
Representative Laura Knaperek
Representative Linda Lopez
Representative Doug Quelland
People with disabilities may request reasonable accommodations such as interpreters,
alternative formats, or assistance with physical accessibility. If you require accommodations,
please contact the Chief Clerk's Office at (602) 926-3032, TOO (602) 926-3241.
ARIZONA STATE LEGISLATURE
SENATE HEALTH AND HOUSE OF REPRESENTATIVES HEALTH COMMITTEE OF
REFERENCE FOR THE:
SUNSET OF THE HEALTH FACILITIES AUTHORITY
SUNSET OF THE MEDICAL RADIOLOGIC TECHNOLOGY BOARD OF EXAMINERS
SUNSET OF THE NURSING CARE INSTITUTION ADMINISTRATION AND
.ASSISTED LIVING
SUNSET OF THE BOARD OF HOMEOPATHIC MEDICAL EXAMINERS
SUNRISE REQUEST OF THE ARIZONA ASSOCIATION FOR HOME CARE
SUNRISE REQUEST OF THE ARIZONA MIDWIFERY INSTITUTE
SUNRISE REQUEST OF THE ARIZONA ALLIANCE OF SURGICAL SPECIALISTS
Minutes of the Meeting
Tuesday, November 8, 2005
9:00 a.m., House Hearing Room 1
Members Present:
Senator Jim Waring, Co-Chair
Senator Carolyn Allen
Senator Marsha Arzberger
Senator Robert Cannell
Senator Barbara Leff .
Members Absent:
Representative David Bradley
Staff:
Beth Kohler, Senate Health Research Analyst
Elizabeth Baskett, House Health Research Analyst
Representative Rick Murphy, Co-Chair
Representative Laura Knaperek
Representative Linda Lopez
Representative Doug Quelland
Co-chairman Murphy called the meeting to order at 9:12 a.m. and attendance was
noted.
Presentation by the Health Facilities Authority
Blaine Sandi, Executive Director, Health Facilities Authority (HFA), stated that his
organization was established in 1977 to issue bonds exempt from income tax on the
Authorities interest which enables them to get lower interest rates. He explained that the
Authority would then Joan their proceeds to health care facilities at lower rates than the
healthcare facilities would receive from banks. Mr. Bandi remarked that the Authority
provided low cost loans for rural and underserved healthcare facilities.
He stated that rural communities that have benefited from the program included:
• Flagstaff
• Kingman
• Prescott
• Wickenburg
• Douglas
• Springerville
• Page
• Sisbee
• Camp Verde
• Fort Mojave
• Peach Springs
• Sacaton
• Elfrida
• Morenci
• Ajo
• St. Michaels
Mr. Sandi remarked that the Health Facilities Authority was not a regulatory agency and
that it existed solely to improve the health care for the residents of Arizona through the
financing of critical health care projects. He remarked that failure to continue the
Authority would deprive the State's health care providers of a needed source of tax
exempt financing. He respectfully requested the Committee of Reference recommend
the Arizona Health Facilities Authority be continued for ten years.
In response to Senator Cannell's question about the possibility of a hospital not paying
their loan back, Mr. Sandi told the Committee that since the inception of the HFA in
1977, this had only occurred once. He remarked that payments by that hospital were
still being made to HFA. Mr. Sandi added that the residents of the State have no legal
obligation to back up those bonds because they were issued solely on the credit of the
institution.
Representative Knaperek asked Mr. Sandi to list the seven directors for HFA and he did
so as follows:
1. Bruce Gulledge, health care underwriter who does financing for health
care institutions across the country.
2. Donald Shropshire, former hospital administrator; Tucson Medical
Center.
3. Jennifer Ryan, community health center director from Southern Arizona.
4. Rufus Glasper, Chancellor of the Maricopa County Community College
District.
SENATE HEALTH AND HOUSE HEALTH COMMITTEE
OF REFERENCE
Tuesday, November 8, 2005
Page 2
5. William Emerson, City Attorney for the City of Peoria.
6. Susan Straussner, Community Health Nurse from Parnell County.
7. Steven Russo, Sond Attorney based in Tucson.
In response to Representative Knaperek's question about funding, Mr. Sandi told the
Committee that the HFA's annual budget was approximately $300,000 per year and that
revenues to the Authority were generated through bond financing activities. He stated
that when the HFA approved bonds, applicants are paying one basis point, which is .01
of one percent of total financing. He remarked that additionally applicants paid 7.5 basis
points which was equal to .075 percent. Mr. Sandi told the Committee that the HFA
brought in between $300,000 to one million dollars per year, a five year cycle with one
million dollars every fifth year. He added that the extra money was used for loans to
other healthcare facilities in underserved parts of the State. Mr. Sandi told the
Committee that the credit rate was predicated on a number of things, the most
prominent being the credit worthiness of the applicant and also on the term and purpose
of the loan. He remarked that he had seen the interest rates in the range of about four
percent up to about seven percent.
Representative Knaperek asked the amount of savings in interest rates there was for
people who used the HFA services. Mr. Sandi responded that historically, the industry
used a figure of 15 percent savings going to tax exempt financing versus taxable
financing. He stated that today, when interest rates are lower, that 15 percent figure
would be closer to 10 or 11 percent.
In response to Representative Quelland, Mr. Sandi stated that the title holder on any
property in which the HFA loaned money is going to be that non-profit corporation. He
remarked that the HFA had liens on record for every loan they do. Mr. Sandi explained
that the bond financing has specific guidelines and rules the HFA must follow in the
event of a default.
In response to Senator Leff, Mr. Sandi told the Committee that HFA hired a lobbyist
solely from lack of experience with legislative scenarios and to help the organization
navigate through the process.
Representative Quelland moved that the Senate Health and House
Health Committee of Reference recommend to continue the Health
Facilities Authority Board for ten years. By voice vote, the motion
CARRIED.
Presentation by the Medical Radiologic Technology Board of Examiners
Aubrey Godwin, Director, Radiation Regulatory Agency, told the Committee that the
Medical Radiologic Technology Board of Examiners (MRTBE) was created in 1977 by
SENATE HEALTH AND HOUSE HEALTH COMMITTEE
OF REFERENCE
Tuesday, November 8, 2005
Page 3
legislation due to the large number of unqualified technicians in the State. He stated that
the role of MRTBE was to make sure that technicians or people applying ionizing
radiation to a human being had been properly trained. He remarked that the type of
technologist observed by MRTBE were X-ray, therapy, nuclear medicine and
mammography technologists. Mr. Godwin pointed out that nuclear medicine technology
had been added recently to MRTBE's certification program. He stated that MRTBE
presently had approximately 9,000 certificate holders, some of whom hold dual
certification. Mr. Godwin pointed out that most of the MRTBE cases dealing with
disciplinary matters were related to failure to pay dues or questionable certifications
since their last sunset review.
In response to Senator Allen, Mr. Godwin explained that drug treatment was made
available through MRTBE for certified technicians who may need it and failure to
successfully complete these proceedings would result in termination of certification.
In response to Senator Cannell, Mr. Godwin said that most of the drug related issues
with technicians took place in larger institutions such as hospitals as opposed to private
physician offices. He stated that if the institution where a troubled technician worked
had a drug treatment program, MRTBE would direct the technician to utilize that
program and if not, the technician would attend an independent drug program paid for
by the technician.
In response to Senator Arzberger, Mr. Godwin remarked that due to the different State
requirements for technician certification, out of town applicants must be certified in
Arizona before working in this State.
In response to Representative Knaperek, Mr. Godwin told the Committee that there
were both nationally certified and non-nationally certified radiological technician schools
in Arizona. He stated that the vacancy on MRTBE had been available for less than one
year.
In response to Representative Murphy, Mr. Godwin told the Committee that he looked
forward to finding a citizen to fill the vacancy on the MRTBE.
In response to Representative Knaperek, Mr. Godwin remarked that due to the shortage
of technicians in the State, Arizona has experienced an influx of out of State
technicians.
In response to Senator Allen, John Gray, Program Manager, MRTBE, informed the
Committee that a high school graduate could enter into the field of radiological
technology either through community college or privately funded programs. He added
that private school training took two years or less.
In response to Senator Leff, Mr. Godwin stated that there was a continuing education
requirement in place for the field of radiological technology due to changing technology.
SENATE HEALTH AND HOUSE HEALTH COMMITIEE
OF REFERENCE
Tuesday, November 8, 2005
Page 4
Public Testimony
Jerry High, Arizona State Society of Radiologic Technologists, told the Committee
that out of concern for public safety, he was glad that certification was required before
becoming a technician.
In response to Senator Left, Mr. Hyde said that passing the "Registry," a test sponsored
by the American Association of Radiologic Technology (AART) was very difficult, yet
allowed him to be nationally certified.
In response to Senator Left, Mr. Godwin told the Committee that radiologic
technologists were certified professionals, not licensed professionals.
Stephen Sapareto, Director of Medical Physics, Banner Good Samaritan Hospital,
stated that he was the boss of the technologists at his facility and expressed the
importance of technologists to be certified. He pointed out that another group certified
by MRTBE were radiologic therapists, who administered ongoing care such as
chemotherapy, and that it was especially important for these therapists to be certified.
~' response to Senator Left, Mr. Safereto explained that radiologic technologists and
therapists had a chief technologist or therapist supervising them, followed by a chain of
command that ultimately led to a physician at his facility.
Jeff Siupik, Director of Radiation Services, MRTBE told ~he Committee that being a
director of technologists, he is concerned about the shortage of technologists in the
State due to strict standards by the MRTBE on non-local technologist operating
machinery in a crisis situation.
Senator Left opined that two weeks, the time it takes for MRTBE to certify a non-local
technician, was not a long period of time.
Representative Quelland moved that the Senate Health and House
Health Committee of Reference recommend to continue the Medical
Radiologic Technology Board of Examiners for ten years. The motion
CARRIED by voice vote.
Presentation by the Board of Examiners of Nursing Care Institution
Administrators and Assisted Living Facility Managers
Allen Imig, Executive Director, Board of Examiners of Nursing Care Institution
Administrators and Assisted Living Facility Managers (BENCIAIALFM), informed
the Committee that the Board was created in 1975 to protect the public's health and
welfare by regulating and licensing nursing care institution administrators. He stated that
in 1990, the board statutes were amended to add the responsibility of certifying and
regulating adult home care managers and renamed in 1998 to Assisted Living Facility
Managers. The mission of the Board was to protect the health, welfare and safety of its
SENATE HEALTH AND HOUSE HEALTH COMMITIEE
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citizens, to seek and institute the use of services of nursing care institution
administrators and assisted living facility managers. Mr. Imig said that the Board's
procedures helped ensure quality and competency standards were met by
administrators and managers. In addition, the Board approves continuing education
courses to make sure quality and useful education is being taught. He explained that
since June of 2005, the Board had undergone an "extreme makeover" with virtually all
new members being appointed. This reduced the back log of uninvestigated complaints
significantly, Mr. Imig told the Committee that the Board had reduced their staff from five
to three, leaving an executive director, investigator and a licensing coordinator. He
encouraged the Committee to continue the BENCIAIALFM.
In response to Senator Allen, Mr. Imig said that the Board consisted of five managers,
two public members and the remaining members were administrators.
Senator Allen opined that home care nursing staff deserved better pay.
In response to Senator Waring, Mr. Imig stated that the changes made to the Board has
helped, but not solved its financial problems.
In response to Senator Arzberger, Mr. Imig said that his Board investigated complaints
from citizens regarding private care nurses and administrators as well as complaints
filed by the Department of Health Services.
In response to Senator Waring, Mr. Imig told the Committee that the Board's website
contained information regarding decisions on disciplinary action.
In response to Senator Allen, Mr. Imig explained that out of the last renewal period for
managers, 2,000 of 2,500-2,600 renewal notices sent were renewed, causing 578
expired notices to be sent by the Board. .
In response to Senator Leff, Mr. Imig opined that his Board received between 60 and 70
complaints a year, mainly not health care related but administrative related.
In response to Senator Waring, Mr. Imig stated that with the current staff, the Board
should catch up on its back log of complaints by January 2006.
In response to Representative Quelland, Mr. Imig remarked that the Board was actively
seeking replacements for the three vacancies on the Board.
Senator Leff suggested that the Committee send a letter to the Governor encouraging
her to appoint the three positions.
In response to Representative Quelland, Mr. Imig opined that he would like to see a five
year continuation be given to the Board.
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Representative Knaperek remarked that time elected to the Board would reflect
concerns with term limits and not reflect faith in Mr. Imig.
Public Testimony
Robert Frechettee, President, Arizona Health Care Association (AHCA), told the
Committee that on behalf of his Board, he would like to offer support in the continuation
of the BENCIA/ALFM. He opined that the efforts implemented by the new staff showed
that the Board was very serious about suggestions and concerns brought forth by the
Legislature.
In response to Senator Waring, Mr. Bruschette stated that the AHCA was seen as the
organization that represented the for profit facilities, containing some non-profit facilities
and representing assisted living communities and independent full service communities.
He said that Assisted Living Federation represents assisted living centers in homes and
the Arizona Association of Homes for the Aging represents a number of facilities seen
as non-profit businesses.
In response to Senator Cannell, Mr. Bruschette opined that if fee increases were
ffecessary to fund the continuation of the Board, that it would be supported by AHCA.
Senator Leff stated that if the Committee made a five year recommendation at this
meeting and the audit comes out in December and is changed, the legislation coming
out in January does not have to be the same as the recommendation.
Representative Knaperek told the Committee that Mr. Imig had a good work history as a
Director in other fields.
In response to Representative Knaperek, Beth Kohler, Senate Health Research Analyst,
stated that the first audit of the Board would take place approximately six months after
nomination adding an 18 month follow up audit, only if the requirements and
recommendations made by the report were not met.
Representative Ouelland moved that the Senate Health and House
Health Committee of Reference recommend that the Board of
Examiners of Nursing Care Institution Administrators and Assisted
Living Facility Managers be continued for two years. The motion
FAILED.
Representative Ouelland moved that the Senate Health and House
Health Committee of Reference recommend that the Board of
Examiners Nursing Care Institution Administrators and Assisted
Living Facility Managers be continued for five years pending the
findings of the Auditor General's report due in December of 2005.
The motion CARRIED..
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Presentation by the Board of Homeopathic Medical Examiners
Chris Springer, Executive Director, Homeopathic Board, told the Committee that
she had worked for the Board of Homeopathic Medical Examiners (BHME) since 1999.
She complimented appointments made to the Board by all of the Governors on both the
Democrat and Republican side. She opined that the laws governing the licensing of
homeopathic physicians set forth by the State had been upheld. Ms. Springer stated
that a potential audit could be helpful in improving procedures and welcomed the
process of an impartial audit. She said that the Board currently has 117 licensed
homeopathic physicians.
Senator Leff opined that it was nice to hear Ms. Springer suggest an audit of the Board
and noted that BHME had gone approXimately 20 years without an audit.
Senator Allen opined that she would like to see an audit of the BHME as well. She
added that in no way did legislation intend to do away with the homeopathic form of
medicine.
In response to Representative Lopez, Ms. Springer stated that a licensed homeopathic
physician could only continue to practice in one state after receiving disciplinary action
in another state for less than one year, due to the Board's annual. renewal application
required of all homeopathic physicians, which would discover the violation in the other
~~e. .
In response to Representative Murphy, Ms. Springer said that there was the possibility
of a physician being dishonest about any past disciplinary action, however, there is a
standard penalty in place for such an event.
In response to Senator Waring, Ms. Springer told the Committee that there was not an
easily accessible data base of criminal background checks for physicians and added
that the fee to search names on the federal data base was $3.75 per name.
Senator Leff opined that being dishonest on an application should have strong
consequences for any physician when dealing with the subject matter of past
disciplinary action.
Dr. Charles Schwengel, President of the Homeopathic Medical Licensing Board,
told the Committee that being dishonest on an application was the most egregious of
unprofessional conduct that could happen.
In response to Representative Knaperek, Ms. Springer stated that a physician lying on
the application was discovered once and a letter of concern was issued.
Representative Knaperek opined that there should be a certain amount of consideration
afforded to the applicant on whether the incident was an issue of forgetfulness or
deliberate intent.
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In response to Senator Cannell, Ms. Springer stated that setting aside funds to check
each individual physician's background would be a step in the right direction.
Senator Allen remarked that the concerns stated today could be addressed in the
forthcoming audit.
In response to Representative Quelland, Ms. Springer told the Committee that some
traditional doctors became homeopathic physicians, and then dropped their traditional
medical license.
In response to Representative Quelland's comments on a medical doctor dropping their
license to pursue homeopathy due to decreased chances of medical malpractice
occuring, Dr. Schwengel remarked that he could not comment on the personal reasons
a physician might do this.
In response to Representative Murphy, Ms. Springer stated that the percentage of
homeopathic physicians who were previously licensed as medical doctors was very low.
Re~esentative Murphy told the Committee that some physicians may choose to net
carry medical malpractice insurance to avoid becoming a target for medical malpractice.
Senator Cannell opined that there was a fear with physicians of becoming a target for
medical malpractice by carrying medical malpractice insurance.
In response to Senator Waring, Ms. Springer stated that BHME kept records indefinitely
of reported complaints against homeopathic physicians. She told the Committee that in
her opinion, the BHME should only keep records for up to five years similar to other
medical boards.
In response to Senator Waring, Ms. Springer remarked that she felt it necessary to keep
records of complaints for longer than five years, only if they were substantiated.
In response to Senator Allen suggesting that more public members should be on the
BHME, Ms. Springer said that additional public members on the Board would be a good
idea.
Public Testimony
Dr. Kathleen Fry, dually licensed by the Arizona Medical Board and Arizona
Homeopathic Medical Board, told the Committee that she had gathered a large
amount of important information pertaining to the BHME that she would like to share
with the Legislature and the Office of the Auditor General. She stated that she had been
committed to the practice of homeopathic and alternative medicine for twenty years in
Scottsdale, Arizona. She remarked that it was not her intent to keep patients from
receiving homeopathic care. Dr. Fry opined that the BHME had been grossly negligent
SENATE HEALTH AND HOUSE HEALTH COMMITTEE
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in its spiritual, moral and judicial responsibilities to protect the public from unscrupulous
physicians by licensing felons, failing to adequately discipline physicians who had
harmed patients, failing to adequately file complaints against other board members and
by giving licenses to physicians who could not pass a basic oral examination of
homeopathy. She stated that when she was recruited to the BHME in 1994, she was
informed by the Board that her dues were necessary to keep the Board in existence and
to allow her to continue to practice homeopathic medicine. Dr. Fry remarked that the
dues for the Association were $1000 per year in addition to the $500 per year licensing
fee and the $150 dispensing fee. She explained that if a homeopathic physician in
Arizona lost their M.D. license in another state, they could still practice homeopathy
here in Arizona which gives that physician the power to write prescriptions for all
classes of drugs, conduct minor surgery in their office, perform acupuncture and various
other medical techniques. In conclusion, Dr. Fry told the Committee that the
homeopathic license gives the physician a much broader range of modalities that they
can use with much less scrutiny and training.
In response to Senator Waring, Dr. Fry stated that in theory, physicians who had marks
on their records in other states should be rehabilitated in that state before being allowed
a license in Arizona, but that had not always been the case.
In response to Representative Knaperek, Dr. Fry remarked that transcripts from board
meetings that she had obtained from Ms. Springer, were public record. .
In response to Senator Leff, Dr. Fry explained that a device called a sputnik originated
in Russia and is swallowed by a patient and designed to kill parasites by radiation. She
told the committee that a physician sold the device to a patient in Florida over the
phone, and that upon taking this device orally, the patient developed a bowel
obstruction resulting in the removal of several feet of her intestine. She added that the
said physician, being one of the originators of the BHME, only received a letter of
concern and an apology by the Board for placing that letter in the physicians file.
In response to Senator Waring, Dr. Springer told the Committee that she disagreed with
Ms. Fry's perception of the Board.
Dr. Todd Rowe, Homeopathic and Integrative Medical Physician, Desert Institute
of Classical Homeopathy, dually licensed, told the Committee that he had been
practicing homeopathic medicine for over twenty years. He urged the Committee to
continue the BHME. He remarked that after attending several meetings over the years
of the BHME, he had found most of what Dr. Fry said to be untrue.
In response to Senator Cannell, Dr. Rowe stated that the number of out-of-state
homeopathic physicians licensed in Arizona was very small. He explained that Arizona
was one of only three states who had homeopathy boards and that this was another
reason for an increase in out-of-state applicants in this State.
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In response to Senator Left, Dr. Rowe said that his homeopathy school had a 1,000
hour program for homeopathy, with plans on expanding that program to 4,000 hours
within the next few years.
In response to Senator Left, Dr. Rowe stated that the qualifications for a license for
homeopathy consisted of either 40 hours of class of homeopathy, in addition to 300
hours of alternative medicine, or 90 hours of class for homeopathy. He opined that this
met the minimum requirements to become a homeopathic physician and commented on
the fact that some applicants were already licensed medical doctors.
Lee Bakunin, practicing attorney in Arizona for 36 years, representing self, told the
committee that he had spent the last eleven years of his life studying homeopathy. He
explained that after the required 90 hours, there was no continuing education required
to continue practicing homeopathy. Mr. Bakunin said that the Auditor General may
come across the problem of incomplete records of past BHME meetings.
In response to Representative Quelland, Mr. Bakunin said that he currently had studied
about 2,000 hours of homeopathy.
G1adys Conroy, patient of homeopathy, representing self stated that homeopathy
had saved her life. She told the Committee that standard medication caused her great
danger.
Clifford Heinrich, practicing family physician for alternative medicines, opined that
no alternative medical board· should be able to have jurisdiction over the spiritual
practice of homeopathy. He added that he had obtained over 1,200 hours of
homeopathy. Dr. Heinrich told the Committee that he had a petition with 200 signatures
recognizing homeopathy as a spiritual practice. He stated that he had an additional
petition to request the Legislature audit the BHME for "reasons previously addressed in
the meeting."
In response to Senator Allen, Dr. Heinrich opined that· homeopathy was being
misrepresented by the BHME from its original spiritual foundation, causing the public to
believe they were receiving homeopathic care when in fact, they were not.
In response to Representative Knaperek question about· the spiritual aspect of
homeopathy, Dr. Heinrich explained that a nonmaterial substance was one that had
been diluted to a point where the original property is no longer there, leaving only the
essence of that object.
In response to Representative Murphy, Dr. Heinrich told the Committee that he wanted
the separation between homeopathy and alternative medicines distinguished by the
State.
Amanya Jacobs, Director of Evolution of Self/Soul School Homeopathy, remarked
that she was deeply committed to making homeopathy available to all citizens in the
SENATE HEALTH AND HOUSE HEALTH COMMITTEE
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State. She said that the Board regulated activities that it deemed homeopathy which
were totally unrelated to that area of medicine. Ms. Jacobs stated that she was in favor
of an audit of the BHME.
Linda Heming, Arizona Homeopathic and Integrative Medical Association, told the
committee that western medicine could not help her and homeopathy saved her life.
Senator Leff remarked that the open meeting law stated that recordings and minutes
must be kept by the open body and must be accurate and open for inspection three
days after the meeting, with no language about whether or not they could be destroyed
at any time period.
Russell Olinsky, patient of homeopathy, spoke in favor of the BHME.
Cynthia MacLuskie, patient of homeopathy, told the Committee that all homeopathy
medicines were not available at health food stores and that prescriptions were the only
way to obtain some of these medicines.
Lisa Platt, Arizona Homeopathic and Integrative Medical Association, speaking on
behalf of the BHME, remarked that BHME was not recruiting felons. She stated that a
number of patients had told her how homeopathy had saved theirlives.'
Senator Allen moved that the Senate Health and House Health
Committee of Reference recommend that the Board of Homeopathic
Medical Examiners continue for two years, adding the request for an
audit addressing the concerns covered in today's committee.
Representative Quelland explained his vote. He said that although he did not have an
educational background in homeopathy, the homeopathic physicians had a certain
amount of disagreement and confusion among themselves. He reminded the
Committee that this was just a recommendation and that someone was going to create
a bill and that bill would be voted on, making today's vote not a guarantee that the
Board will continue, and he voted "aye."
Senator Cannell explained his vote. He said that although he advocated homeopathy
and the continuation of the Board, that the BHME had suffered a "major black eye"
today. He opined that the director and the president of the boards had not changed their
attitudes and that they should consider their Board a precious commodity by not diluting
their group of good physicians with out of state applicants with questionable credentials
and he voted "aye."
Senator Leff explained her vote. She requested the Auditor General to do both a
financial and performance audit. She remarked that the people who came forward today
against the Board should feel free to do so without retaliation and she voted "aye."
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Senator Waring explained his vote. He said that he was very frustrated with the Board,
and that he would be the first to vote "no" on a bill in the following session if changes
weren't made, but since today's vote was merely a recommendation, he would vote
"aye."
Representative Murphy explained his vote. He said that he shared many of the
concerns voiced by the Committee members today and looked forward to hearing what
the Auditor General had to say and he voted "aye."
The motion CARRIED by a roll call vote of 9-0-1 (Attachment 1).
Representative Murphy RECESSED the meeting at 1:35 p.m. to the sound of the gavel.
Representative Murphy RECONVENED the meeting at 2:30 p.m.
Presentation by the Arizona Midwifery Institute
Marinah Valenzuela Farrell, President of the Arizona Midwifery Institute (AMI),
submitted handouts (Attachment A) and (Attachment B) to the Committee. She told the
Comfuittee that as midwives, their main concern was for safe outcomes of mothers,and
babies. She remarked that midwives chose home birth because they believe that birth is
a natural and safe event in the life of a woman. Ms. Farrell explained that in the 1970's,
midWifery became licensed in the State, yet because of medical liability issues,
midwives had experienced difficulty in consults with physicians and access to items to
assist in home birth. .
In response to Senator Allen, Ms. Farrell stated that midwife licensing exams were very
tough and that she had received specialized intravenous training in New Mexico through
the local hospital.
In response to Senator Cannell, Ms. Farrell told the Committee that licensing of
midwives was dependent upon number of hours of experience in child birth delivery with
that applicant. She stated that there were also schools available to midwives that
involved intense clinical training. Ms. Farrell said that a surveyor in the Department of
Special Licensure administered a national exam to applicants in which upon passing,
the applicant must then go through an oral board and upon passing this, must complete
a practical exam which is overseen by the surveyor and· other midwives. She told the
Committee that midwives were trained in resuscitating babies.
In response to Senator Leff, Ms. Farrell stated that the midwives were requesting that a
physician not be required to sign off on supplies.
Representative Lopez opined that her own personal experience of giving birth to her last
two children at home from midwives was a wonderful experience.
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Representative Quelland informed the Committee that Arizona had 53 licensed
midwives with 22 of them located in Maricopa County and that there were 343 midwife
births in the home in 2004 in the State.
In response to Representative Quelland, Ms. Farrell remarked that none of the 343
reported midwife births reported in 2004 resulted in any problems. She stated that
although medical malpractice and liability insurance was available to midwives, the
majority refused it due to its cost in proportion to their pay. She told the Committee that
the Arizona Health Care Cost Containment System (AHCCCS) discontinued the
payment for midwife delivery two years ago due to midwives not carrying medical
malpractice and liability insurance which could possibly put AHCCCS at risk for such
claims.
Senator Leff stated that midwives dealt mostly with low-risk births and that she would
like to see the issue of AHCCCS discontinuing payment for midwife births examined.
Senator Cannell opined that the Committee should hear from AHCCCS because they
obviously found midwifery funds a financial risk for some legitimate reason.
Ms. Farrell told the Committee that mothers who chose home births mainly did so, not
for financial reasons, but because of belief that the hospital environment was just one
intervention leading to another.
Public Testimony
Rory Hays, Arizona Nurses Association, said that the items asked for by the AMI
were appropriate, if accompanied by more training. She stated that she opposed
expanding prescription privileges for anything requiring a Drug Enforcement Agency
number.
In response to Representative Quelland, Ms. Hays said that certification would be
appropriate for midwives.
Ms. Farrell stated that the only thing midwives were requesting was the power to obtain
items already in their reach through a physician, without that physician's pre-approval
and that the laws were already in place on limitations for uses with these items.
Representative Quelland moved that the Senate Health and House
Health Committee of Reference recommend that the Legislature
expand the scope of practice for Arizona's licensed midwives by
allowing procurement, possession, and administration of various
medical devices and medications which will be named in the bill. The
motion was CARRIED by voice vote.
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Senator Allen opined that midwifery was a choice to be made by the citizen and she
hoped that fatalities did not occur due to the choice of using such a method.
Presentation by the Arizona Association for Home Care
Suzanne Gilstrap, representing the patients for the Arizona Association for Home
Care (AAHC), stated that AAHC was founded in 1983 with a mission to advance quality
home care as an integral component of the health care delivery system. She told the
Committee that she believed in continuing education for home care providers. She
remarked that AAHC had discussed having a joint workshop with the Physical Therapy
Association (PTA) but never actually initiated these workshops. Ms. Gilstrap requested
that the Committee grant an expansion to allow physical therapy assistants to work
under general supervision of a physical therapist as opposed to direct supervision. She
told the Committee that the AAHC respectfully requested the joint Committee
recommend that physical therapy assistants be allowed to practice in the home health
care setting and only in that setting under the following conditions:
• The supervising physical therapist shall be solely responsible for
evaluating the patient and determining a plan of care.
• The supervising physical therapist shall be available at all times via
telecommunication while the physical therapist assistant is providing
treatment interventions.
• The supervising physical therapist supervises no more than two physical
therapy assistants. .
• The supervising physical therapist shall see the patient and revise the plan
of care no less than every 21 days.
• The supervising physical therapist not assign responsibilities to the
physical therapy assistants that in any way allow them to provide
evaluation services for procedures.
• Continuing education requirements should be added to the statute as well.
• The physical therapist would be the one responsible for final evaluation
and discharge of the patient.
In response to Senator Arzberger, Ms. Gilstrap said that proposing a mileage limit would
be a good idea in reference to a physical therapist along with the constant
telecommunication contact. She stated that it was not unusual to recommend that the
practice of home care be extended to other areas outside of the home such as
hospitals.
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In response to Senator Left, Ms. Gilstrap remarked that the AAHC was not intending to
mandate what physical therapists do, but to enable legislation that would allow them to
choose.
In response to Representative Murphy, Ms. Gilstrap stated that home care therapist
assistants were well schooled for their job no matter what setting, with the exception of
no clinical experience required of the physical therapist.
In response to Senator Waring, Ms. Gilstrap remarked that in all fields of medicine,
health care providers were experiencing an inability to serve patients.
Representative Lopez opined that an outside organization should not be directing
physical therapists on how to conduct their practice.
In response to Senator Allen, Ms. Gilstrap told the Committee that currently more than
45 states allow general supervision in the home health care setting and that the only
two states that do not allow it are Pennsylvania and Arizona.
Public Testimony
Karen Jeselun, President of the Arizona Association for Home Care, stated that
even if there were no home care physical therapist available at the time, a patient could
still be released from the hospital even though they required home care to continue
recovery. Ms. Jeselun compared the relationship between a physical therapist and a
physical therapist assistant to that of a registered nurse and a licensed practical nurse.
She told the Committee that all of their home care providers go through an interview
process, a mandatory criminal background check and participate in orientation often
with preceptors.
In response to Representative Knaperek, Ms. Jeselun stated that Medicare currently
paid home health agencies on an episode basis, meaning for every 60 days of time that
patient is in the care of a home health provider, the home care provider gets a lump
sum. She opined that she was hoping to serve more patients with no increase in cost.
Susie Stevens, representing the Arizona Physical Therapy Association (AZPTA),
informed the Committee that the definitions of general supervision and direct
supervision needed to be reviewed. She stated that she was there in opposition to the
sunrise request.
Heidi Herbst Paakkonen, Executive Director of the Arizona Board of Physical
Therapy (ABPT), told the Committee that the ABPT regulates about 3,200 physical
therapists and 434 physical therapist assistants. She said that due to lack of detailed
information at this time, she would encourage the Board to oppose the Sunrise
Application of the AAHC.
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Page 16
In response to Representative Knaperek, Ms. Paakkonen remarked that there were
exactly 3,268 licensed in the State but not all of them worked in Arizona. She told the
Committee that approXimately 2,800 physical therapists listed Arizona addresses. She
stated that there were 434 physical therapy assistants and that approximately 396
reside in Arizona and that it was ABPT's estimate that 350 of them were currently
working in the field of physical therapy.
In response to Representative Quelland, Ms. Paakkonen stated that the ABPT was
required by statute to have three physical therapists and two public members, but no
physical therapist assistants.
In response to Senator Left, Ms. Paakkonen told the Committee that the ABPT does
and has disciplined physical therapist assistants.
Bob Direnfeld, President of the Arizona Physical Therapy Association (AZPTA),
remarked that his organization was the only one in the State representing physical
therapists. He told the Committee that his association opposed the idea of general
supervision. Mr. Direnfeld said that patients were getting discharged from the hospital
too early in most cases compared to years ago, which cause a greater need for these
home care physicians. He remarked that a therapist was ultimately responsible for
anything the physical therapy assistant does which puts the physical therapist's license
on the line.
In response to Representative Murphy, Mr. Direnfeld opined that passing legislation
supporting general care could potentially decrease an even larger amount of physical
therapists.
In response to Senator Cannell, Mr. Direnfeld stated that he was not sure that there was
a shortage in home health care providers. He also remarked that setting a parameter or
definition of a home care patient, would cut down on the patient load.
Representative Knaperek opined that physical therapist assistants should have more of
a vote on the Board.
Peter Zawicki, in favor of the sunrise recommendation, told the Committee that
physical therapists and physical therapist assistants were trained at community colleges
and technical schools across the country. He opined that it was critical that there be
communication between the physical therapist and the physical therapist assistant in all
patient care.
In response to Senator Cannell, Mr. Zawicki stated that physical therapist assistants
were under direct supervision during the education process.
In response to Representative Murphy, Mr. Zawicki remarked that to be able to perform
in public health care, it would be helpful if a physical therapist assistant had a certain
amount or certain tvoe of trainina. J' ~
SENATE HEALTH AND HOUSE HEALTH COMMITTEE
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Page 17
Senator Left opined that home health patients are the most vulnerable patients and she
felt uncomfortable "experimenting" with the care of those patients.
Kerry Halcomb, Physical Therapy on Wheels, representing AAHC, opined that he
did not believe that a physical therapist could adequately supervise a physical therapist
assistant.
Gayle Haas, physical therapist, representing AAHC, remarked that a physical
therapist and a physical therapist assistant can work together for years and develop a
relationship which allowed for better understanding and communication skills with one
another.
Deborah Bornmann, physical therapist, stated that she did not feel represented by
her own board. She opined that it was great for an outside organization to try to help
physical therapists.
Representative Quelland moved that the Senate Health and House
Health Committee of Reference recommend that the Legislature
expand the scope of practice for licensed physical therapist
assistants by allowing home health visits under the general
. supervision of licensed physical therapists. The motion was
CARRIED by voice vote.
Senator Waring stated that although he was unhappy with what he had heard
today, he hoped discussions were started to improve the situation.
Representative Knaperek remarked that she hoped they could work out their
differences for the benefit of the State.
Senator Arzberger opined that changes do need to be made and issues need to
be addressed.
Representative Murphy stated that hopefully, this would get people back into
discussions.
There being no further business, the meeting was adjourned at 5:12 p.m.
RespectfUlly submitted,
Jeff Turner
Committee Secretary
(Tapes and attachments on file in the Secretary of the Senate's Office/Resource Center, Room 115.)
SENATE HEALTH AND HOUSE HEALTH COMMITTEE
OF REFERENCE
Tuesday, November 8, 2005
Page 18
Senate Health and House of Representatives Health Committee
of Reference
ARIZONA STATE LEGISLATURE
FORTY-FIFTH LEGISLATURE - ROLL CALL VOTE
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Pr R€Q\)£5~ . 'E2 f2. AI\J !JUDI T \3\1 WE AvD 11""0 (L Ge]'Jt:"l2-!Jt. i
Rep. Bradley
Rep. Lopez
Rep. Quelland
Senator Allen
Senator Arzberger
Senator Cannell
Senator Left
Senator Waring, CoChair
Rep. Murphy, CoChair
Committee Secretary j.f7Pl?: =rJfZ...Nbf<- Date \ 1-01) ~dOO<)
Attachment~
November 8,2005

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Arizona House of Representatives
House Majority Research
MEMORANDUM
Kristine Stoddar~
Assistant Legislative Research Analyst
(602) 926-5299
To: JOINT LEGISLATIVE AUDIT COMMITTEE
1700 W. Washington
Phoenix, AZ 85007-2848
FAX (602) 417-3140
cc: Representative Rick Murphy, Chair
Senator Jim Waring, Vice-Chair
Re: Sunrise application of the Arizona Midwifery Institute
Date: December 2, 2005
Attached is the final report ofthe sunrise request submitted by the Arizona Midwifery Institute,
which was conducted by the Senate Health and House of Representatives Health Committee of
Reference.
This report has been distributed to the following individuals and agencies:
Governor ofthe State ofArizona
The Honorable Janet Napolitano
President ofthe Senate
Senator Ken Bennett
Senate Members
Senator Jim Waring, Vice-Chair
Senator Carolyn Allen
Senator Marsha Arzberger
Senator Robert Cannell
Senator Barbara Leff
Arizona Midwifery Institute
Department of Library, Archives & Public Records
Auditor General
Senate Republican Staff
Senate Research Staff
Senate Democratic Staff
Speaker ofthe House of Representatives
Representative Jim Weiers
House Members
Representative Rick Murphy, Chair
Representative David Bradley
Representative Laura Knaperek
Representative Linda Lopez
Representative Doug Quelland
House Majority Staff
House Research Staff
House Democratic Staff
Senate Health and House ofRepresentatives Health
Committee ofReference Report
Sunrise Request ofArizona Midwifery Institute
Date: December 2, 2005
To: Joint Legislative Audit Committee
Representative Rick Murphy, Chair
Senator Jim Waring, Vice-Chair
Background
Pursuant to Arizona Revised Statutes (ARS) §32-3104, the Joint Legislative Audit
Committee assigned a sunrise review for licensed midwives to the Senate Health and
House of Representatives Health Committee of Reference. Attached is a copy of the
application submitted by the Arizona Midwifery Institute (Institute).
Authorized by Laws 1957, Chapter 45, §1 the Midwife Licensing Program licenses and
regulates midwife services in Arizona. The Midwife Licensing Program is administered
by the Office of Special Licensure within the Arizona Department of Health Services
(DHS). Current state law and DHS rule prohibits licensed midwives from providing care
to any woman who has a history of or develops serious conditions including a previous
Cesarean section, a history of severe postpartun bleeding, sexually transmitted diseases,
unhealthy blood pressure levels, premature labor, abnormal fetal heart rate, postpartum
hemorrhage, etc. Furthermore, licensed midwives must obtain medical consultation to
obtain a recommendation for treatment, referral or transfer of care at any time that their
client is determined to have serious medical problems during their pregnancy.
DHS rule further stipulates that, in emergency situations, licensed midwives may only
perform the following procedures:
1. Cardiopulmonary resuscitation of the mother or newborn;
2. Administration of oxygen at no more than 8 liters per minute via mask for the
mother and 5 liters per minute for the newborn via neonatal mask;
3. Midline episiotomy to expedite the delivery during fetal distress;
4. Suturing of episiotomy or tearing of the perineum, to stop active bleeding,
following administration of local anesthetic, contingent upon physician
consultation or standing orders of physician;
5. Release of shoulder dystocia by rotating the shoulders into one of the oblique
diameters of the pelvis; and
6. Manual exploration of the uterus for control of severe bleeding.
The Arizona Midwifery Institute is requesting that the Legislature grant licensed
midwives a scope of practice increase by amending the licensed midwives statute to
permit Arizona licensed midwives to obtain, possess and administer, without the orders
ofa physician, the following:
• Oxytocins
RH immunoglobin
• IV fluid replacement
• Local anesthetics
• Vitamin K
• Eve prophylaxis
Oxygen
• Devices for rupturing the amniotic sac
• Devices for repairing birth reiated lacerations
• Specified devices for resuscitation
• Devices for the administration of intravenous fluids
• Needles and syringes
Committee ofReference Sunrise Review Procedures
The Committee of Reference held one public meeting on November 8, 2005 to review the
Institute's sunrise application as required by ARS §32-3104 and to hear public testimony
on the proposed changes.
Committee ofReference Recommendations
The Committee of Reference recommends that the Legislature expand the scope of
practice for Arizona's licensed midwives by allowing procurement, possession, and
administration of various medical devices and medications, which will be specified in
legislation.
Attachments:
1. Sunrise application submitted by the Arizona Midwifery Institute.
2. Meeting notice.
3. Minutes of the Committee of Reference meeting.
Elizabeth Basl~ett
Health Comnrittee Analyst
(602) 926-3072
Arizona House of Representatives
House Majority Research
MEMORANDUM
1700 W. Washington
Phoenix,AZ 85007-2848
FAX (602) 417-3095
To: Members ofthe House Health and Senate Health Committees ofReference
Re: Sunrise Request of the Arizona Midwifery Institute
Date: October 26, 2005
The following is some background information regarding the request for an increase in the scope
ofpractice for licensed midwives. Also attached is a copy of the sunrise application submitted by
the Arizona Midwifery Institute (AMI). A public meeting is scheduled for November 8th to allow
you to ask questions, take public testimony and make a final recommendation on the sunrise
application. If you have questions or need additional information, please feel free to contact me.
BACKGROUND
According to statute, a midwife is a person who delivers a baby or provides health care related to
pregnancy, labor, delivery and postpartum care of the mother and her baby. A midwife is not a
physician. A midwife practices the independent management of care for healthy, low· risk
women, and their infants during pregnancy, labor and birth, and in the first few weeks after birth.
In this state, midwives are authorized to deliver babies in the home. In Arizona, there are two
types of midwives who may legally assist a woman with childbirth: a certified nurse midwife
and a licensed midwife. The Sunrise application only applies to licensed midwives because
certified nurse midwives already have prescription privileges.
Authorized by Laws 1957, Chapter 45, §1 the Midwife Licensing Program licenses and regulates
midwife services in Arizona. The Midwife Licensing Program is administered by the Office of
Special Licensure within the Arizona Department ofRealth Services (DRS).
October 26, 2005
According to A.R.S. § 36-755(B) 4 and Arizona Administrative Code Title 9, Chapter 16, to
qualify for a midwife license, an applicant must be at least 18 years old; have a high school
diploma or its equivalent; be of good moral character; be currently certified by the American
Heart Association in adult basic cardiopulmonary resuscitation and be currently certified by the
American Academy of Pediatrics in neonatal cardiopulmonary resuscitation. Additionally,
applicants must submit a letter of recommendation from a certified nurse-midwife, a licensed
midwife, or a physician and a letter of recommendation from a mother for whom the applicant
has provided midwifery services. A license must be renewed biennially. Furthermore, DHS rule
requires an applicant for midwifery take a three part examination consisting of a written section,
oral section and a practical section. Applicants must receive a grade of 80% or higher to be
licensed.
Licensed midwives are also required to obtain 10 continuing education units which are related to
maintaining the skills and judgment necessary to:
1. Assess a client for acceptance and monitor the client's ongoing condition;
2. Plan and manage care during the normal prenatal, intra partum, and postpartum
periods;
3. Intervene when the client's condition deviates from normal.
4. Provide emergency assistance, as permitted, until medical care can be obtained;
5. Offer anticipatory guidance and support on an ongoing basis for the client and family
including nutritional counseling, substance abuse cessation, encouragement for early
and continuous care for mother and infant, and motivate the client to establish a
relationship with a primary care provider; and
6. Provide referral services to medical and community services as appropriate for the
client's needs.
There are approximately 54 Arizona licensed midwives. Midwives currently practice in 7
counties in Arizona. There is not a state approved program of midwifery training in Arizona at
this time.
SCOPE OFPRACTICE INCREASE
Current state law and DRS rule prohibits licensed midwives from providing care to any woman
who has a history of or develops serious conditions including a previous Cesarean section, a
history of severe postpartun bleeding, sexually transmitted diseases, unhealthy blood pressure
levels, premature labor, abnormal fetal heart rate, postpartum hemorrhage, etc. Furthermore,
2
October 26, 2005
licensed midwives must obtain medical consultation to obtain a recommendation for treatment,
referral or transfer of care at any time that their client is determined to have serious medical
problems during their pregnancy.
DHS rule further stipulates that, in emergency situations, licensed midwives may only perform
the following procedures:
1. Cardiopulmonary resuscitation ofthe mother or newborn;
2. Administration of oxygen at no more than 8 liters per minute via mask for the mother
and 5 liters per minute for the newborn via neonatal mask;
3. Midline episiotomy to expedite the delivery during fetal distress;
4. Suturing of episiotomy or tearing of the perineum, to stop active bleeding, following
administration of local anesthetic, contingent upon physician consultation or standing
orders ofphysician;
5. Release of shoulder dystocia by rotating the shoulders into one of the oblique
diameters of the pelvis; and
6. Manual exploration ofthe uterus for control of severe bleeding.
Additionally, current law limits a licensed midwife to administering a maximum does of 20 units
ofpitocin intramuscularly, in lO-unit dosages each, 30 minutes apart, to a client for the control of
postpartum hemorrhage, contingent upon physician consultation or standing orders by a
physician, and arrangements for immediate transport of the client to a hospital.
The Arizona Midwifery Institute is requesting that the Legislature grant licensed midwives a
scope of practice increase by amending the licensed midwives statute to permit Arizona
licensed midwives to obtain, possess and administer, without the orders of a physician, the
following:
•
��
•
•
•
•
•
•
•
•
•
Oxytocins
RH immunoglobin
IV fluid replacement
Local anesthetics
VitaminK
Eve prophylaxis
Oxygen
Devices for rupturing the amniotic sac
Devices for repairing birth related lacerations
Specified devices for resuscitation
Devices for the administration ofintravenous fluids
Needles and syringes
3
October 26, 2005
According to the AMI, the scope of practice increase has only recently become necessary
because of current malpractice issues in Arizona. Specifically, the AMI alleges that malpractice
insurance companies are restricting physicians from prescribing the abovementioned medications
and devices for use by midwives. Additionally, the AMI states that the current Arizona law
presents obstacles to safe homebirth deliveries by "limiting skilled professional midwives access
to necessary drugs and devices." The AMI also states that allowing midwives access to
emergency and non-emergency medications and devices would enable midwives to practice
within their skills and educational level.
According to the AMI "the benefit to the consumer, who for personal or economical reasons
prefer homebirths, is that midwives will be able to provide safer outcomes for mother and their
families."
OTHER STATES
About 27 states authorize the administration of specified medications/drugs and devices.
Although some states allow certified nurse-midwives prescriptive authority, staff was only able
to identify five states that authorize licensed midwives to prescribe medications/drugs and
devices, these state laws are detailed below. It important to note that several state laws are silent
on the issue and several states authorize the health department or health profession board to
prescribe rules regarding medications and devices.
Oregon - Oregon state law allows a licensed midwife to purchase and administer authorized
scheduled legend drugs and devices that are used in pregnancy, birth, postpartum care, newborn
care or resuscitation and that are deemed integral to providing safe care to the public by the State
Board of Direct Entry Midwifery by rule. Legend drugs authorized are limited to prophylactic
ophthalmic medications, vitamin K and oxygen; and Rho (D) immune globulin, epinephrine,
intravenous fluids, local anesthetic and legend devices for injection of medications, for the
administration of intravenous fluids, for adult and infant resuscitation and for rupturing the
amniotic membranes. Pharmacists who dispense drugs and devices to a licensed midwife are not
liable for any adverse reactions caused by administration of the legend drugs and devices by the
midwife.
Washington - Washington administrative rule allows a licensed midwife to obtain and
administer prophylactic ophthalmic medication, postpartum oxytocic, vitamin K, Rho immune
4
October 26, 2005
globulin and local anesthetic. A pharmacist who dispenses such drugs to a licensed midwife is
not liable for any adverse reactions caused by any method of use by the midwife.
New Hampshire - New Hampshire state law allows a licensed midwife to obtain, without
prescription, the following medications: Rh immune globin (Rhogam), Eye prophylaxis.
Oxygen, Lidocaine Hydrochloride by infiltration and suture material,Vitamin K by injection or
oral vitamin, Oxytocins such as pitocin, ergotrate, and methergine, by injection or orally and
Intravenous fluids. A pharmacist who dispenses such medications to a certified midwife is not
liable for any adverse reactions caused by any method of use by the midwife.
New York - New York law grants a licensed midwife the authority, as necessary, limited to the
practice of midwifery and subject to limitations in the written agreement, to prescribe and
administer drugs, immunizing agents, diagnostic tests and devices, as established by the health
board in accordance with the health commissioner's regulations. A midwife must obtain a
certificate upon successfully completing a program including a pharmacology component, or its
equivalent, as established by the commissioner's regulations prior to prescribing medications or
devices.
Utah - Utah State created a Licensed Direct-entry Midwife Formulary Committee charged with
the adoption of a licensed direct-entry midwife formulary. A rule was then adopted to include
prescription drugs which may be obtained by a licensed midwife and the standards, conditions
and guidelines for the use ofprescription drugs included in the formulary.
5
1. A definition of the problem and why a change in the scope of practice is necessary,
including the extent to which consumers need and will benefit from licensed midwives with
this scope of practice.
This sunrise application seeks permission and direction, pursuant to A.RS.§ 32-3106, to
amend the licensed midwife statute topermit Arizona licensed midwives to obtain, possess and
administer the following:
• Oxytocins
• RH immunoglobin
• N fluid replacement
• Local anesthetics
• VitaminK
• Eye prophylaxis
• Oxygen
• Devices for rupturing the amniotic sac
• Devices for repairing birth relatedlacerations
• Specified devices for resuscitation
• Devices for the administration ofintravenous fluids
• Needles and syringes
The reason this has not been a problem until now is because ofcurrent malpractice insurance
issues in Arizona. Previously, malpractice insurance companies did not restrict physicians to
work with midwives by prescribing the abovementioned medications and devices.
This increased scope of practice would permit licensed midwives to practice within the
framework ofthe International Definition ofMidwifery:
"Amidwife is a person who, having been regularly admitted to a midwifery educational
program, duly recognized in the country in which it is located, has successfully
completed the prescribed course ofstudies in midwifery and has acquired the requisite
qualifications to be registered and/orlegally licensed to practice midwifery.
She must be able to give the necessary supervision, care and advice to women during
pregnancy, labor and the postpartum period, to conduct deliveries on her own
responsibility andto.care for the newborn and the infant This care includes preventative
measures, the detection ofabnormal conditions in mother and child, the procurement of
medical assistance and the execution ofemergency measures in the absence ofmedical
help. She has an important task in health counseling and education, not only for the
women, but also within the family and the community. The work should involve
antenatal education and preparation for parenthood and extends to certain areas of
gynecology, family planning and child care. She may practice in hospitals, clinics,
health units, domiciliary conditions or in any other service."
This definition is accepted by the WorId Health Organization and the International
Confederation ofMidwives. Currently, in the United States, there are about 27 states that allow
the administration ofthe abovementioned medications/drugs and devices bymidwives who are
either licensed or certified.
I
The benefit to the consumer, who for personal or economic reasons prefers homebirths, is
that midwives will be able to provide safer outcomes for mothers and their families.
According to the British Medical Journal in late June 2005:
"Researchers looked at more than 5,000 planned home births with professional
midwives in the U.S. and Canada. They found 87 percent ofmothers and babies did not
need to be transferred to a hospital."
Further, the average homebirth costs about 60 percent less than a hospital birth. Additionally:
"The study also found the use ofmedical interventions, such as forceps, epidurals, and
Caesarian Sections to be less than half ofthose in low-risk hospital births." ,
The current Arizona law presents obstacles to safe homebirth deliveries by limiting skilled
professional midwives access to necessary drugs and devices. Further, allowingmidwives access
to certain emergency and nonemergency medications and devices would enable midwives to
practice within their skills and education level.
2. The extent to which the public can be confident that qualified practitioners are competent.
Arizona Administrative Code Title 9, Chapter 16 describes current education requirements
for all midwives licensed by the Arizona Department ofHealth Services.
Additionally, skilled professional midwives licensed to practice midwifery in Arizona are
required to continue their education with current Continuing Education Units per Arizona
legislation. Lastly, the role ofthe Arizona Midwifery Institute (AMI), Code ofEthics, midwifery
model ofcare and supporting the role ofmidwives will aid midwives in maintaining skills and
working to improve midwifery services. The AMI mission statement follows:
"The Arizona Midwifery Institute is a professional organization dedicated to
strengthening relationships among health care professionals, legislators, and the
community to promote and implement the Midwives Model of Care."
3. The extent to which an increased scope of practice may harm the public.
The applicants anticipate that significant client and health benefits will follow from the
enactment of the proposed practice expansion and anticipate no harm to the public from the
appropriate acquisition and administration ofthe aforementioned drugs and devices.
This enactment will ensure that mothers and their families receive the highest quality ofcare
midwives can provide.
4. The estimated cost to the state and the general public of implementing the proposed
increase in scope of practice.
There is no financial impact to the state or the public for midwives to obtain, possess and
administer the aforementioned drugs and devices.
Interim agendas can be obtained via the Internet at http://www.azleg.state.az.us/lnterimCommittees.asp
ARIZONA STATE LEGISLATURE
INTERIM MEETING NOTICE
OPEN TO THE PUBLIC
SENATE HEALTH AND HOUSE OF REPRESENTATIVES HEALTH
COMMITTEE OF REFERENCE FOR THE:
SUNSET OF THE HEALTH FACILITIES AUTHORITY
SUNSET OF THE MEDICAL RADIOLOGIC TECHNOLOGY BOARD OF EXAMINERS
SUNSET OF THE NURSING CARE INSTITUTION ADMINISTRATION AND ASSISTED LIVING
SUNSET OF THE BOARD OF HOMEOPATHIC MEDICAL EXAMINERS
SUNRISE REQUEST OF THE ARIZONA ASSOCIATION FOR HOME CARE
SUNRISE REQUEST OF THE ARIZONA MIDWIFERY INSTITUTE
SUNRISE REQUEST OF THE ARIZONA ALLIANCE OF SURGICAL SPECIALISTS
Date:
Time:
Place:
Tuesday, November 8,2005
9:00 a.m.
House Hearing Room 1
AGENDA
1. Call to Order - Opening Remarks
2. Health Facilities Authority
• Presentation by the Health Facilities Authority
• Public Testimony
• Discussion and Recommendations by Committee of Reference
3. Medical Radiologic Technology Board of Examiners
• Presentation by the Medical Radiologic Technology Board of Examiners
• Public Testimony
• Discussion and Recommendations by Committee of Reference
4. Nursing Care Institution Administration and Assisted Living Facility Managers Board
• Presentation by the Nursing Care Institution Administration and Assisted Living
Facility Managers Board
• Public Testimony
• Discussion and Recommendations by Committee of Reference
5. Board of Homeopathic Medical Examiners
• Presentation by the Board of Homeopathic Medical Examiners
• Public Testimony
• Discussion and Recommendations by Committee of Reference
6. Arizona Alliance of Surgical Specialists
• Presentation by the Arizona Alliance of Surgical Specialists
• Public Testimony
• Discussion and Recommendations by Committee of Reference
7. Arizona Association for Home Care
• Presentation by the Arizona Association for Home Care
• Public Testimony
• Discussion and Recommendations by Committee of Reference
8. Arizona Midwifery Institute
• Presentation by the Arizona Midwifery Institute
• Public Testimony
• Discussion and Recommendations by Committee of Reference
9. Adjourn
Members:
Senator Jim Waring, Co-Chair
Senator Carolyn Allen
Senator Marsha Arzberger
Senator Robert Cannell
Senator Barbara Leff
10/31/05
jmb
Representative Rick Murphy, Co-Chair
Representative David Bradley
Representative Laura Knaperek
Representative Linda Lopez
Representative Doug Quelland
People with disabilities may request reasonable accommodations such as interpreters,
alternative formats, or assistance with physical accessibility. If you require accommodations,
please contact the Chief Clerk's Office at (602) 926-3032, TOO (602) 926-3241.
ARIZONA STATE LEGISLATURE
SENATE HEALTH AND HOUSE OF REPRESENTATIVES HEALTH COMMITTEE OF
REFERENCE FOR THE:
SUNSET OF THE HEALTH FACILITIES AUTHORITY
SUNSET OF THE MEDICAL RADIOLOGIC TECHNOLOGY BOARD OF EXAMINERS
SUNSET OF THE NURSING CARE INSTITUTION ADMINISTRATION AND
.ASSISTED LIVING
SUNSET OF THE BOARD OF HOMEOPATHIC MEDICAL EXAMINERS
SUNRISE REQUEST OF THE ARIZONA ASSOCIATION FOR HOME CARE
SUNRISE REQUEST OF THE ARIZONA MIDWIFERY INSTITUTE
SUNRISE REQUEST OF THE ARIZONA ALLIANCE OF SURGICAL SPECIALISTS
Minutes of the Meeting
Tuesday, November 8, 2005
9:00 a.m., House Hearing Room 1
Members Present:
Senator Jim Waring, Co-Chair
Senator Carolyn Allen
Senator Marsha Arzberger
Senator Robert Cannell
Senator Barbara Leff .
Members Absent:
Representative David Bradley
Staff:
Beth Kohler, Senate Health Research Analyst
Elizabeth Baskett, House Health Research Analyst
Representative Rick Murphy, Co-Chair
Representative Laura Knaperek
Representative Linda Lopez
Representative Doug Quelland
Co-chairman Murphy called the meeting to order at 9:12 a.m. and attendance was
noted.
Presentation by the Health Facilities Authority
Blaine Sandi, Executive Director, Health Facilities Authority (HFA), stated that his
organization was established in 1977 to issue bonds exempt from income tax on the
Authorities interest which enables them to get lower interest rates. He explained that the
Authority would then Joan their proceeds to health care facilities at lower rates than the
healthcare facilities would receive from banks. Mr. Bandi remarked that the Authority
provided low cost loans for rural and underserved healthcare facilities.
He stated that rural communities that have benefited from the program included:
• Flagstaff
• Kingman
• Prescott
• Wickenburg
• Douglas
• Springerville
• Page
• Sisbee
• Camp Verde
• Fort Mojave
• Peach Springs
• Sacaton
• Elfrida
• Morenci
• Ajo
• St. Michaels
Mr. Sandi remarked that the Health Facilities Authority was not a regulatory agency and
that it existed solely to improve the health care for the residents of Arizona through the
financing of critical health care projects. He remarked that failure to continue the
Authority would deprive the State's health care providers of a needed source of tax
exempt financing. He respectfully requested the Committee of Reference recommend
the Arizona Health Facilities Authority be continued for ten years.
In response to Senator Cannell's question about the possibility of a hospital not paying
their loan back, Mr. Sandi told the Committee that since the inception of the HFA in
1977, this had only occurred once. He remarked that payments by that hospital were
still being made to HFA. Mr. Sandi added that the residents of the State have no legal
obligation to back up those bonds because they were issued solely on the credit of the
institution.
Representative Knaperek asked Mr. Sandi to list the seven directors for HFA and he did
so as follows:
1. Bruce Gulledge, health care underwriter who does financing for health
care institutions across the country.
2. Donald Shropshire, former hospital administrator; Tucson Medical
Center.
3. Jennifer Ryan, community health center director from Southern Arizona.
4. Rufus Glasper, Chancellor of the Maricopa County Community College
District.
SENATE HEALTH AND HOUSE HEALTH COMMITTEE
OF REFERENCE
Tuesday, November 8, 2005
Page 2
5. William Emerson, City Attorney for the City of Peoria.
6. Susan Straussner, Community Health Nurse from Parnell County.
7. Steven Russo, Sond Attorney based in Tucson.
In response to Representative Knaperek's question about funding, Mr. Sandi told the
Committee that the HFA's annual budget was approximately $300,000 per year and that
revenues to the Authority were generated through bond financing activities. He stated
that when the HFA approved bonds, applicants are paying one basis point, which is .01
of one percent of total financing. He remarked that additionally applicants paid 7.5 basis
points which was equal to .075 percent. Mr. Sandi told the Committee that the HFA
brought in between $300,000 to one million dollars per year, a five year cycle with one
million dollars every fifth year. He added that the extra money was used for loans to
other healthcare facilities in underserved parts of the State. Mr. Sandi told the
Committee that the credit rate was predicated on a number of things, the most
prominent being the credit worthiness of the applicant and also on the term and purpose
of the loan. He remarked that he had seen the interest rates in the range of about four
percent up to about seven percent.
Representative Knaperek asked the amount of savings in interest rates there was for
people who used the HFA services. Mr. Sandi responded that historically, the industry
used a figure of 15 percent savings going to tax exempt financing versus taxable
financing. He stated that today, when interest rates are lower, that 15 percent figure
would be closer to 10 or 11 percent.
In response to Representative Quelland, Mr. Sandi stated that the title holder on any
property in which the HFA loaned money is going to be that non-profit corporation. He
remarked that the HFA had liens on record for every loan they do. Mr. Sandi explained
that the bond financing has specific guidelines and rules the HFA must follow in the
event of a default.
In response to Senator Leff, Mr. Sandi told the Committee that HFA hired a lobbyist
solely from lack of experience with legislative scenarios and to help the organization
navigate through the process.
Representative Quelland moved that the Senate Health and House
Health Committee of Reference recommend to continue the Health
Facilities Authority Board for ten years. By voice vote, the motion
CARRIED.
Presentation by the Medical Radiologic Technology Board of Examiners
Aubrey Godwin, Director, Radiation Regulatory Agency, told the Committee that the
Medical Radiologic Technology Board of Examiners (MRTBE) was created in 1977 by
SENATE HEALTH AND HOUSE HEALTH COMMITTEE
OF REFERENCE
Tuesday, November 8, 2005
Page 3
legislation due to the large number of unqualified technicians in the State. He stated that
the role of MRTBE was to make sure that technicians or people applying ionizing
radiation to a human being had been properly trained. He remarked that the type of
technologist observed by MRTBE were X-ray, therapy, nuclear medicine and
mammography technologists. Mr. Godwin pointed out that nuclear medicine technology
had been added recently to MRTBE's certification program. He stated that MRTBE
presently had approximately 9,000 certificate holders, some of whom hold dual
certification. Mr. Godwin pointed out that most of the MRTBE cases dealing with
disciplinary matters were related to failure to pay dues or questionable certifications
since their last sunset review.
In response to Senator Allen, Mr. Godwin explained that drug treatment was made
available through MRTBE for certified technicians who may need it and failure to
successfully complete these proceedings would result in termination of certification.
In response to Senator Cannell, Mr. Godwin said that most of the drug related issues
with technicians took place in larger institutions such as hospitals as opposed to private
physician offices. He stated that if the institution where a troubled technician worked
had a drug treatment program, MRTBE would direct the technician to utilize that
program and if not, the technician would attend an independent drug program paid for
by the technician.
In response to Senator Arzberger, Mr. Godwin remarked that due to the different State
requirements for technician certification, out of town applicants must be certified in
Arizona before working in this State.
In response to Representative Knaperek, Mr. Godwin told the Committee that there
were both nationally certified and non-nationally certified radiological technician schools
in Arizona. He stated that the vacancy on MRTBE had been available for less than one
year.
In response to Representative Murphy, Mr. Godwin told the Committee that he looked
forward to finding a citizen to fill the vacancy on the MRTBE.
In response to Representative Knaperek, Mr. Godwin remarked that due to the shortage
of technicians in the State, Arizona has experienced an influx of out of State
technicians.
In response to Senator Allen, John Gray, Program Manager, MRTBE, informed the
Committee that a high school graduate could enter into the field of radiological
technology either through community college or privately funded programs. He added
that private school training took two years or less.
In response to Senator Leff, Mr. Godwin stated that there was a continuing education
requirement in place for the field of radiological technology due to changing technology.
SENATE HEALTH AND HOUSE HEALTH COMMITIEE
OF REFERENCE
Tuesday, November 8, 2005
Page 4
Public Testimony
Jerry High, Arizona State Society of Radiologic Technologists, told the Committee
that out of concern for public safety, he was glad that certification was required before
becoming a technician.
In response to Senator Left, Mr. Hyde said that passing the "Registry," a test sponsored
by the American Association of Radiologic Technology (AART) was very difficult, yet
allowed him to be nationally certified.
In response to Senator Left, Mr. Godwin told the Committee that radiologic
technologists were certified professionals, not licensed professionals.
Stephen Sapareto, Director of Medical Physics, Banner Good Samaritan Hospital,
stated that he was the boss of the technologists at his facility and expressed the
importance of technologists to be certified. He pointed out that another group certified
by MRTBE were radiologic therapists, who administered ongoing care such as
chemotherapy, and that it was especially important for these therapists to be certified.
~' response to Senator Left, Mr. Safereto explained that radiologic technologists and
therapists had a chief technologist or therapist supervising them, followed by a chain of
command that ultimately led to a physician at his facility.
Jeff Siupik, Director of Radiation Services, MRTBE told ~he Committee that being a
director of technologists, he is concerned about the shortage of technologists in the
State due to strict standards by the MRTBE on non-local technologist operating
machinery in a crisis situation.
Senator Left opined that two weeks, the time it takes for MRTBE to certify a non-local
technician, was not a long period of time.
Representative Quelland moved that the Senate Health and House
Health Committee of Reference recommend to continue the Medical
Radiologic Technology Board of Examiners for ten years. The motion
CARRIED by voice vote.
Presentation by the Board of Examiners of Nursing Care Institution
Administrators and Assisted Living Facility Managers
Allen Imig, Executive Director, Board of Examiners of Nursing Care Institution
Administrators and Assisted Living Facility Managers (BENCIAIALFM), informed
the Committee that the Board was created in 1975 to protect the public's health and
welfare by regulating and licensing nursing care institution administrators. He stated that
in 1990, the board statutes were amended to add the responsibility of certifying and
regulating adult home care managers and renamed in 1998 to Assisted Living Facility
Managers. The mission of the Board was to protect the health, welfare and safety of its
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citizens, to seek and institute the use of services of nursing care institution
administrators and assisted living facility managers. Mr. Imig said that the Board's
procedures helped ensure quality and competency standards were met by
administrators and managers. In addition, the Board approves continuing education
courses to make sure quality and useful education is being taught. He explained that
since June of 2005, the Board had undergone an "extreme makeover" with virtually all
new members being appointed. This reduced the back log of uninvestigated complaints
significantly, Mr. Imig told the Committee that the Board had reduced their staff from five
to three, leaving an executive director, investigator and a licensing coordinator. He
encouraged the Committee to continue the BENCIAIALFM.
In response to Senator Allen, Mr. Imig said that the Board consisted of five managers,
two public members and the remaining members were administrators.
Senator Allen opined that home care nursing staff deserved better pay.
In response to Senator Waring, Mr. Imig stated that the changes made to the Board has
helped, but not solved its financial problems.
In response to Senator Arzberger, Mr. Imig said that his Board investigated complaints
from citizens regarding private care nurses and administrators as well as complaints
filed by the Department of Health Services.
In response to Senator Waring, Mr. Imig told the Committee that the Board's website
contained information regarding decisions on disciplinary action.
In response to Senator Allen, Mr. Imig explained that out of the last renewal period for
managers, 2,000 of 2,500-2,600 renewal notices sent were renewed, causing 578
expired notices to be sent by the Board. .
In response to Senator Leff, Mr. Imig opined that his Board received between 60 and 70
complaints a year, mainly not health care related but administrative related.
In response to Senator Waring, Mr. Imig stated that with the current staff, the Board
should catch up on its back log of complaints by January 2006.
In response to Representative Quelland, Mr. Imig remarked that the Board was actively
seeking replacements for the three vacancies on the Board.
Senator Leff suggested that the Committee send a letter to the Governor encouraging
her to appoint the three positions.
In response to Representative Quelland, Mr. Imig opined that he would like to see a five
year continuation be given to the Board.
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Representative Knaperek remarked that time elected to the Board would reflect
concerns with term limits and not reflect faith in Mr. Imig.
Public Testimony
Robert Frechettee, President, Arizona Health Care Association (AHCA), told the
Committee that on behalf of his Board, he would like to offer support in the continuation
of the BENCIA/ALFM. He opined that the efforts implemented by the new staff showed
that the Board was very serious about suggestions and concerns brought forth by the
Legislature.
In response to Senator Waring, Mr. Bruschette stated that the AHCA was seen as the
organization that represented the for profit facilities, containing some non-profit facilities
and representing assisted living communities and independent full service communities.
He said that Assisted Living Federation represents assisted living centers in homes and
the Arizona Association of Homes for the Aging represents a number of facilities seen
as non-profit businesses.
In response to Senator Cannell, Mr. Bruschette opined that if fee increases were
ffecessary to fund the continuation of the Board, that it would be supported by AHCA.
Senator Leff stated that if the Committee made a five year recommendation at this
meeting and the audit comes out in December and is changed, the legislation coming
out in January does not have to be the same as the recommendation.
Representative Knaperek told the Committee that Mr. Imig had a good work history as a
Director in other fields.
In response to Representative Knaperek, Beth Kohler, Senate Health Research Analyst,
stated that the first audit of the Board would take place approximately six months after
nomination adding an 18 month follow up audit, only if the requirements and
recommendations made by the report were not met.
Representative Ouelland moved that the Senate Health and House
Health Committee of Reference recommend that the Board of
Examiners of Nursing Care Institution Administrators and Assisted
Living Facility Managers be continued for two years. The motion
FAILED.
Representative Ouelland moved that the Senate Health and House
Health Committee of Reference recommend that the Board of
Examiners Nursing Care Institution Administrators and Assisted
Living Facility Managers be continued for five years pending the
findings of the Auditor General's report due in December of 2005.
The motion CARRIED..
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Presentation by the Board of Homeopathic Medical Examiners
Chris Springer, Executive Director, Homeopathic Board, told the Committee that
she had worked for the Board of Homeopathic Medical Examiners (BHME) since 1999.
She complimented appointments made to the Board by all of the Governors on both the
Democrat and Republican side. She opined that the laws governing the licensing of
homeopathic physicians set forth by the State had been upheld. Ms. Springer stated
that a potential audit could be helpful in improving procedures and welcomed the
process of an impartial audit. She said that the Board currently has 117 licensed
homeopathic physicians.
Senator Leff opined that it was nice to hear Ms. Springer suggest an audit of the Board
and noted that BHME had gone approXimately 20 years without an audit.
Senator Allen opined that she would like to see an audit of the BHME as well. She
added that in no way did legislation intend to do away with the homeopathic form of
medicine.
In response to Representative Lopez, Ms. Springer stated that a licensed homeopathic
physician could only continue to practice in one state after receiving disciplinary action
in another state for less than one year, due to the Board's annual. renewal application
required of all homeopathic physicians, which would discover the violation in the other
~~e. .
In response to Representative Murphy, Ms. Springer said that there was the possibility
of a physician being dishonest about any past disciplinary action, however, there is a
standard penalty in place for such an event.
In response to Senator Waring, Ms. Springer told the Committee that there was not an
easily accessible data base of criminal background checks for physicians and added
that the fee to search names on the federal data base was $3.75 per name.
Senator Leff opined that being dishonest on an application should have strong
consequences for any physician when dealing with the subject matter of past
disciplinary action.
Dr. Charles Schwengel, President of the Homeopathic Medical Licensing Board,
told the Committee that being dishonest on an application was the most egregious of
unprofessional conduct that could happen.
In response to Representative Knaperek, Ms. Springer stated that a physician lying on
the application was discovered once and a letter of concern was issued.
Representative Knaperek opined that there should be a certain amount of consideration
afforded to the applicant on whether the incident was an issue of forgetfulness or
deliberate intent.
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In response to Senator Cannell, Ms. Springer stated that setting aside funds to check
each individual physician's background would be a step in the right direction.
Senator Allen remarked that the concerns stated today could be addressed in the
forthcoming audit.
In response to Representative Quelland, Ms. Springer told the Committee that some
traditional doctors became homeopathic physicians, and then dropped their traditional
medical license.
In response to Representative Quelland's comments on a medical doctor dropping their
license to pursue homeopathy due to decreased chances of medical malpractice
occuring, Dr. Schwengel remarked that he could not comment on the personal reasons
a physician might do this.
In response to Representative Murphy, Ms. Springer stated that the percentage of
homeopathic physicians who were previously licensed as medical doctors was very low.
Re~esentative Murphy told the Committee that some physicians may choose to net
carry medical malpractice insurance to avoid becoming a target for medical malpractice.
Senator Cannell opined that there was a fear with physicians of becoming a target for
medical malpractice by carrying medical malpractice insurance.
In response to Senator Waring, Ms. Springer stated that BHME kept records indefinitely
of reported complaints against homeopathic physicians. She told the Committee that in
her opinion, the BHME should only keep records for up to five years similar to other
medical boards.
In response to Senator Waring, Ms. Springer remarked that she felt it necessary to keep
records of complaints for longer than five years, only if they were substantiated.
In response to Senator Allen suggesting that more public members should be on the
BHME, Ms. Springer said that additional public members on the Board would be a good
idea.
Public Testimony
Dr. Kathleen Fry, dually licensed by the Arizona Medical Board and Arizona
Homeopathic Medical Board, told the Committee that she had gathered a large
amount of important information pertaining to the BHME that she would like to share
with the Legislature and the Office of the Auditor General. She stated that she had been
committed to the practice of homeopathic and alternative medicine for twenty years in
Scottsdale, Arizona. She remarked that it was not her intent to keep patients from
receiving homeopathic care. Dr. Fry opined that the BHME had been grossly negligent
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in its spiritual, moral and judicial responsibilities to protect the public from unscrupulous
physicians by licensing felons, failing to adequately discipline physicians who had
harmed patients, failing to adequately file complaints against other board members and
by giving licenses to physicians who could not pass a basic oral examination of
homeopathy. She stated that when she was recruited to the BHME in 1994, she was
informed by the Board that her dues were necessary to keep the Board in existence and
to allow her to continue to practice homeopathic medicine. Dr. Fry remarked that the
dues for the Association were $1000 per year in addition to the $500 per year licensing
fee and the $150 dispensing fee. She explained that if a homeopathic physician in
Arizona lost their M.D. license in another state, they could still practice homeopathy
here in Arizona which gives that physician the power to write prescriptions for all
classes of drugs, conduct minor surgery in their office, perform acupuncture and various
other medical techniques. In conclusion, Dr. Fry told the Committee that the
homeopathic license gives the physician a much broader range of modalities that they
can use with much less scrutiny and training.
In response to Senator Waring, Dr. Fry stated that in theory, physicians who had marks
on their records in other states should be rehabilitated in that state before being allowed
a license in Arizona, but that had not always been the case.
In response to Representative Knaperek, Dr. Fry remarked that transcripts from board
meetings that she had obtained from Ms. Springer, were public record. .
In response to Senator Leff, Dr. Fry explained that a device called a sputnik originated
in Russia and is swallowed by a patient and designed to kill parasites by radiation. She
told the committee that a physician sold the device to a patient in Florida over the
phone, and that upon taking this device orally, the patient developed a bowel
obstruction resulting in the removal of several feet of her intestine. She added that the
said physician, being one of the originators of the BHME, only received a letter of
concern and an apology by the Board for placing that letter in the physicians file.
In response to Senator Waring, Dr. Springer told the Committee that she disagreed with
Ms. Fry's perception of the Board.
Dr. Todd Rowe, Homeopathic and Integrative Medical Physician, Desert Institute
of Classical Homeopathy, dually licensed, told the Committee that he had been
practicing homeopathic medicine for over twenty years. He urged the Committee to
continue the BHME. He remarked that after attending several meetings over the years
of the BHME, he had found most of what Dr. Fry said to be untrue.
In response to Senator Cannell, Dr. Rowe stated that the number of out-of-state
homeopathic physicians licensed in Arizona was very small. He explained that Arizona
was one of only three states who had homeopathy boards and that this was another
reason for an increase in out-of-state applicants in this State.
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In response to Senator Left, Dr. Rowe said that his homeopathy school had a 1,000
hour program for homeopathy, with plans on expanding that program to 4,000 hours
within the next few years.
In response to Senator Left, Dr. Rowe stated that the qualifications for a license for
homeopathy consisted of either 40 hours of class of homeopathy, in addition to 300
hours of alternative medicine, or 90 hours of class for homeopathy. He opined that this
met the minimum requirements to become a homeopathic physician and commented on
the fact that some applicants were already licensed medical doctors.
Lee Bakunin, practicing attorney in Arizona for 36 years, representing self, told the
committee that he had spent the last eleven years of his life studying homeopathy. He
explained that after the required 90 hours, there was no continuing education required
to continue practicing homeopathy. Mr. Bakunin said that the Auditor General may
come across the problem of incomplete records of past BHME meetings.
In response to Representative Quelland, Mr. Bakunin said that he currently had studied
about 2,000 hours of homeopathy.
G1adys Conroy, patient of homeopathy, representing self stated that homeopathy
had saved her life. She told the Committee that standard medication caused her great
danger.
Clifford Heinrich, practicing family physician for alternative medicines, opined that
no alternative medical board· should be able to have jurisdiction over the spiritual
practice of homeopathy. He added that he had obtained over 1,200 hours of
homeopathy. Dr. Heinrich told the Committee that he had a petition with 200 signatures
recognizing homeopathy as a spiritual practice. He stated that he had an additional
petition to request the Legislature audit the BHME for "reasons previously addressed in
the meeting."
In response to Senator Allen, Dr. Heinrich opined that· homeopathy was being
misrepresented by the BHME from its original spiritual foundation, causing the public to
believe they were receiving homeopathic care when in fact, they were not.
In response to Representative Knaperek question about· the spiritual aspect of
homeopathy, Dr. Heinrich explained that a nonmaterial substance was one that had
been diluted to a point where the original property is no longer there, leaving only the
essence of that object.
In response to Representative Murphy, Dr. Heinrich told the Committee that he wanted
the separation between homeopathy and alternative medicines distinguished by the
State.
Amanya Jacobs, Director of Evolution of Self/Soul School Homeopathy, remarked
that she was deeply committed to making homeopathy available to all citizens in the
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State. She said that the Board regulated activities that it deemed homeopathy which
were totally unrelated to that area of medicine. Ms. Jacobs stated that she was in favor
of an audit of the BHME.
Linda Heming, Arizona Homeopathic and Integrative Medical Association, told the
committee that western medicine could not help her and homeopathy saved her life.
Senator Leff remarked that the open meeting law stated that recordings and minutes
must be kept by the open body and must be accurate and open for inspection three
days after the meeting, with no language about whether or not they could be destroyed
at any time period.
Russell Olinsky, patient of homeopathy, spoke in favor of the BHME.
Cynthia MacLuskie, patient of homeopathy, told the Committee that all homeopathy
medicines were not available at health food stores and that prescriptions were the only
way to obtain some of these medicines.
Lisa Platt, Arizona Homeopathic and Integrative Medical Association, speaking on
behalf of the BHME, remarked that BHME was not recruiting felons. She stated that a
number of patients had told her how homeopathy had saved theirlives.'
Senator Allen moved that the Senate Health and House Health
Committee of Reference recommend that the Board of Homeopathic
Medical Examiners continue for two years, adding the request for an
audit addressing the concerns covered in today's committee.
Representative Quelland explained his vote. He said that although he did not have an
educational background in homeopathy, the homeopathic physicians had a certain
amount of disagreement and confusion among themselves. He reminded the
Committee that this was just a recommendation and that someone was going to create
a bill and that bill would be voted on, making today's vote not a guarantee that the
Board will continue, and he voted "aye."
Senator Cannell explained his vote. He said that although he advocated homeopathy
and the continuation of the Board, that the BHME had suffered a "major black eye"
today. He opined that the director and the president of the boards had not changed their
attitudes and that they should consider their Board a precious commodity by not diluting
their group of good physicians with out of state applicants with questionable credentials
and he voted "aye."
Senator Leff explained her vote. She requested the Auditor General to do both a
financial and performance audit. She remarked that the people who came forward today
against the Board should feel free to do so without retaliation and she voted "aye."
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Senator Waring explained his vote. He said that he was very frustrated with the Board,
and that he would be the first to vote "no" on a bill in the following session if changes
weren't made, but since today's vote was merely a recommendation, he would vote
"aye."
Representative Murphy explained his vote. He said that he shared many of the
concerns voiced by the Committee members today and looked forward to hearing what
the Auditor General had to say and he voted "aye."
The motion CARRIED by a roll call vote of 9-0-1 (Attachment 1).
Representative Murphy RECESSED the meeting at 1:35 p.m. to the sound of the gavel.
Representative Murphy RECONVENED the meeting at 2:30 p.m.
Presentation by the Arizona Midwifery Institute
Marinah Valenzuela Farrell, President of the Arizona Midwifery Institute (AMI),
submitted handouts (Attachment A) and (Attachment B) to the Committee. She told the
Comfuittee that as midwives, their main concern was for safe outcomes of mothers,and
babies. She remarked that midwives chose home birth because they believe that birth is
a natural and safe event in the life of a woman. Ms. Farrell explained that in the 1970's,
midWifery became licensed in the State, yet because of medical liability issues,
midwives had experienced difficulty in consults with physicians and access to items to
assist in home birth. .
In response to Senator Allen, Ms. Farrell stated that midwife licensing exams were very
tough and that she had received specialized intravenous training in New Mexico through
the local hospital.
In response to Senator Cannell, Ms. Farrell told the Committee that licensing of
midwives was dependent upon number of hours of experience in child birth delivery with
that applicant. She stated that there were also schools available to midwives that
involved intense clinical training. Ms. Farrell said that a surveyor in the Department of
Special Licensure administered a national exam to applicants in which upon passing,
the applicant must then go through an oral board and upon passing this, must complete
a practical exam which is overseen by the surveyor and· other midwives. She told the
Committee that midwives were trained in resuscitating babies.
In response to Senator Leff, Ms. Farrell stated that the midwives were requesting that a
physician not be required to sign off on supplies.
Representative Lopez opined that her own personal experience of giving birth to her last
two children at home from midwives was a wonderful experience.
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Representative Quelland informed the Committee that Arizona had 53 licensed
midwives with 22 of them located in Maricopa County and that there were 343 midwife
births in the home in 2004 in the State.
In response to Representative Quelland, Ms. Farrell remarked that none of the 343
reported midwife births reported in 2004 resulted in any problems. She stated that
although medical malpractice and liability insurance was available to midwives, the
majority refused it due to its cost in proportion to their pay. She told the Committee that
the Arizona Health Care Cost Containment System (AHCCCS) discontinued the
payment for midwife delivery two years ago due to midwives not carrying medical
malpractice and liability insurance which could possibly put AHCCCS at risk for such
claims.
Senator Leff stated that midwives dealt mostly with low-risk births and that she would
like to see the issue of AHCCCS discontinuing payment for midwife births examined.
Senator Cannell opined that the Committee should hear from AHCCCS because they
obviously found midwifery funds a financial risk for some legitimate reason.
Ms. Farrell told the Committee that mothers who chose home births mainly did so, not
for financial reasons, but because of belief that the hospital environment was just one
intervention leading to another.
Public Testimony
Rory Hays, Arizona Nurses Association, said that the items asked for by the AMI
were appropriate, if accompanied by more training. She stated that she opposed
expanding prescription privileges for anything requiring a Drug Enforcement Agency
number.
In response to Representative Quelland, Ms. Hays said that certification would be
appropriate for midwives.
Ms. Farrell stated that the only thing midwives were requesting was the power to obtain
items already in their reach through a physician, without that physician's pre-approval
and that the laws were already in place on limitations for uses with these items.
Representative Quelland moved that the Senate Health and House
Health Committee of Reference recommend that the Legislature
expand the scope of practice for Arizona's licensed midwives by
allowing procurement, possession, and administration of various
medical devices and medications which will be named in the bill. The
motion was CARRIED by voice vote.
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Senator Allen opined that midwifery was a choice to be made by the citizen and she
hoped that fatalities did not occur due to the choice of using such a method.
Presentation by the Arizona Association for Home Care
Suzanne Gilstrap, representing the patients for the Arizona Association for Home
Care (AAHC), stated that AAHC was founded in 1983 with a mission to advance quality
home care as an integral component of the health care delivery system. She told the
Committee that she believed in continuing education for home care providers. She
remarked that AAHC had discussed having a joint workshop with the Physical Therapy
Association (PTA) but never actually initiated these workshops. Ms. Gilstrap requested
that the Committee grant an expansion to allow physical therapy assistants to work
under general supervision of a physical therapist as opposed to direct supervision. She
told the Committee that the AAHC respectfully requested the joint Committee
recommend that physical therapy assistants be allowed to practice in the home health
care setting and only in that setting under the following conditions:
• The supervising physical therapist shall be solely responsible for
evaluating the patient and determining a plan of care.
• The supervising physical therapist shall be available at all times via
telecommunication while the physical therapist assistant is providing
treatment interventions.
• The supervising physical therapist supervises no more than two physical
therapy assistants. .
• The supervising physical therapist shall see the patient and revise the plan
of care no less than every 21 days.
• The supervising physical therapist not assign responsibilities to the
physical therapy assistants that in any way allow them to provide
evaluation services for procedures.
• Continuing education requirements should be added to the statute as well.
• The physical therapist would be the one responsible for final evaluation
and discharge of the patient.
In response to Senator Arzberger, Ms. Gilstrap said that proposing a mileage limit would
be a good idea in reference to a physical therapist along with the constant
telecommunication contact. She stated that it was not unusual to recommend that the
practice of home care be extended to other areas outside of the home such as
hospitals.
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In response to Senator Left, Ms. Gilstrap remarked that the AAHC was not intending to
mandate what physical therapists do, but to enable legislation that would allow them to
choose.
In response to Representative Murphy, Ms. Gilstrap stated that home care therapist
assistants were well schooled for their job no matter what setting, with the exception of
no clinical experience required of the physical therapist.
In response to Senator Waring, Ms. Gilstrap remarked that in all fields of medicine,
health care providers were experiencing an inability to serve patients.
Representative Lopez opined that an outside organization should not be directing
physical therapists on how to conduct their practice.
In response to Senator Allen, Ms. Gilstrap told the Committee that currently more than
45 states allow general supervision in the home health care setting and that the only
two states that do not allow it are Pennsylvania and Arizona.
Public Testimony
Karen Jeselun, President of the Arizona Association for Home Care, stated that
even if there were no home care physical therapist available at the time, a patient could
still be released from the hospital even though they required home care to continue
recovery. Ms. Jeselun compared the relationship between a physical therapist and a
physical therapist assistant to that of a registered nurse and a licensed practical nurse.
She told the Committee that all of their home care providers go through an interview
process, a mandatory criminal background check and participate in orientation often
with preceptors.
In response to Representative Knaperek, Ms. Jeselun stated that Medicare currently
paid home health agencies on an episode basis, meaning for every 60 days of time that
patient is in the care of a home health provider, the home care provider gets a lump
sum. She opined that she was hoping to serve more patients with no increase in cost.
Susie Stevens, representing the Arizona Physical Therapy Association (AZPTA),
informed the Committee that the definitions of general supervision and direct
supervision needed to be reviewed. She stated that she was there in opposition to the
sunrise request.
Heidi Herbst Paakkonen, Executive Director of the Arizona Board of Physical
Therapy (ABPT), told the Committee that the ABPT regulates about 3,200 physical
therapists and 434 physical therapist assistants. She said that due to lack of detailed
information at this time, she would encourage the Board to oppose the Sunrise
Application of the AAHC.
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In response to Representative Knaperek, Ms. Paakkonen remarked that there were
exactly 3,268 licensed in the State but not all of them worked in Arizona. She told the
Committee that approXimately 2,800 physical therapists listed Arizona addresses. She
stated that there were 434 physical therapy assistants and that approximately 396
reside in Arizona and that it was ABPT's estimate that 350 of them were currently
working in the field of physical therapy.
In response to Representative Quelland, Ms. Paakkonen stated that the ABPT was
required by statute to have three physical therapists and two public members, but no
physical therapist assistants.
In response to Senator Left, Ms. Paakkonen told the Committee that the ABPT does
and has disciplined physical therapist assistants.
Bob Direnfeld, President of the Arizona Physical Therapy Association (AZPTA),
remarked that his organization was the only one in the State representing physical
therapists. He told the Committee that his association opposed the idea of general
supervision. Mr. Direnfeld said that patients were getting discharged from the hospital
too early in most cases compared to years ago, which cause a greater need for these
home care physicians. He remarked that a therapist was ultimately responsible for
anything the physical therapy assistant does which puts the physical therapist's license
on the line.
In response to Representative Murphy, Mr. Direnfeld opined that passing legislation
supporting general care could potentially decrease an even larger amount of physical
therapists.
In response to Senator Cannell, Mr. Direnfeld stated that he was not sure that there was
a shortage in home health care providers. He also remarked that setting a parameter or
definition of a home care patient, would cut down on the patient load.
Representative Knaperek opined that physical therapist assistants should have more of
a vote on the Board.
Peter Zawicki, in favor of the sunrise recommendation, told the Committee that
physical therapists and physical therapist assistants were trained at community colleges
and technical schools across the country. He opined that it was critical that there be
communication between the physical therapist and the physical therapist assistant in all
patient care.
In response to Senator Cannell, Mr. Zawicki stated that physical therapist assistants
were under direct supervision during the education process.
In response to Representative Murphy, Mr. Zawicki remarked that to be able to perform
in public health care, it would be helpful if a physical therapist assistant had a certain
amount or certain tvoe of trainina. J' ~
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Senator Left opined that home health patients are the most vulnerable patients and she
felt uncomfortable "experimenting" with the care of those patients.
Kerry Halcomb, Physical Therapy on Wheels, representing AAHC, opined that he
did not believe that a physical therapist could adequately supervise a physical therapist
assistant.
Gayle Haas, physical therapist, representing AAHC, remarked that a physical
therapist and a physical therapist assistant can work together for years and develop a
relationship which allowed for better understanding and communication skills with one
another.
Deborah Bornmann, physical therapist, stated that she did not feel represented by
her own board. She opined that it was great for an outside organization to try to help
physical therapists.
Representative Quelland moved that the Senate Health and House
Health Committee of Reference recommend that the Legislature
expand the scope of practice for licensed physical therapist
assistants by allowing home health visits under the general
. supervision of licensed physical therapists. The motion was
CARRIED by voice vote.
Senator Waring stated that although he was unhappy with what he had heard
today, he hoped discussions were started to improve the situation.
Representative Knaperek remarked that she hoped they could work out their
differences for the benefit of the State.
Senator Arzberger opined that changes do need to be made and issues need to
be addressed.
Representative Murphy stated that hopefully, this would get people back into
discussions.
There being no further business, the meeting was adjourned at 5:12 p.m.
RespectfUlly submitted,
Jeff Turner
Committee Secretary
(Tapes and attachments on file in the Secretary of the Senate's Office/Resource Center, Room 115.)
SENATE HEALTH AND HOUSE HEALTH COMMITTEE
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Tuesday, November 8, 2005
Page 18
Senate Health and House of Representatives Health Committee
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Rep. Bradley
Rep. Lopez
Rep. Quelland
Senator Allen
Senator Arzberger
Senator Cannell
Senator Left
Senator Waring, CoChair
Rep. Murphy, CoChair
Committee Secretary j.f7Pl?: =rJfZ...Nbf